Provider Demographics
NPI:1154312460
Name:SWANSON, MARK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:SWANSON
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 1:1416 E MOREHEAD ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2926
Mailing Address - Country:US
Mailing Address - Phone:704-333-0741
Mailing Address - Fax:704-333-3356
Practice Address - Street 1:1416 E MOREHEAD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2926
Practice Address - Country:US
Practice Address - Phone:704-333-0741
Practice Address - Fax:704-333-3356
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22844174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8981140Medicaid
202013Medicare ID - Type Unspecified
NC8981140Medicaid