Provider Demographics
NPI:1912329889
Name:MARK D WALSH
Entity type:Organization
Organization Name:MARK D WALSH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D. AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-653-0163
Mailing Address - Street 1:7611 HIGHWAY 76
Mailing Address - Street 2:SUITE C
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-9162
Mailing Address - Country:US
Mailing Address - Phone:864-546-5570
Mailing Address - Fax:864-546-5571
Practice Address - Street 1:7611 HIGHWAY 76
Practice Address - Street 2:SUITE C
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-9162
Practice Address - Country:US
Practice Address - Phone:864-546-5570
Practice Address - Fax:864-546-5571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20774OtherLICENSE
SCG91630Medicare UPIN