Provider Demographics
NPI:1053500785
Name:MARK B WILLIAMSON, MD PA
Entity Type:Organization
Organization Name:MARK B WILLIAMSON, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BASCOM
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-838-7091
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0746
Mailing Address - Country:US
Mailing Address - Phone:704-838-7091
Mailing Address - Fax:704-838-7093
Practice Address - Street 1:218 OLD MOCKSVILLE RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1930
Practice Address - Country:US
Practice Address - Phone:704-838-7091
Practice Address - Fax:704-838-7093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700161207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE5245OtherMEDICARE RAILROAD
NC2340966Medicare PIN