Provider Demographics
NPI:1093771107
Name:KILGUS, MARK DUANE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DUANE
Last Name:KILGUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:10 PATEWOOD DR STE 130
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6317
Practice Address - Country:US
Practice Address - Phone:864-522-5550
Practice Address - Fax:864-522-5555
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012410862084P0800X
TNMD366572084P0800X
SC149952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4106719OtherBCBS
TNTN01BEOtherJOHN DEERE
E71310Medicare UPIN
TN3876695Medicare ID - Type Unspecified
VAP00448241Medicare PIN
TNTN01BEOtherJOHN DEERE