Provider Demographics
NPI:1417395500
Name:KROM, MARK B (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:KROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8617
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-220-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC017038Medicaid
SC017038Medicaid