Provider Demographics
NPI:1659344810
Name:REYNOLDS, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:REYNOLDS
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-665-7941
Mailing Address - Fax:843-665-1257
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:STE 260
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506
Practice Address - Country:US
Practice Address - Phone:843-665-7941
Practice Address - Fax:843-665-1257
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC198412086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89063PKOtherNC MEDICAID
SC198413Medicaid
SC198413Medicaid
SCC33856Medicare UPIN