Provider Demographics
NPI:1497980064
Name:VIRTUE, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VIRTUE
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 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3209
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:330 TURNER MCCALL BLVD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5630
Practice Address - Country:US
Practice Address - Phone:706-291-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124619GMedicaid
GA003124619AMedicaid
GA202I083919Medicare PIN