Provider Demographics
NPI:1740227156
Name:MARK THOMAS MAHONEY, D.O., P.C.
Entity Type:Organization
Organization Name:MARK THOMAS MAHONEY, D.O., P.C.
Other - Org Name:MAHONEY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:276-666-0500
Mailing Address - Street 1:100 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112
Mailing Address - Country:US
Mailing Address - Phone:276-666-0500
Mailing Address - Fax:276-666-0400
Practice Address - Street 1:100 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112
Practice Address - Country:US
Practice Address - Phone:276-666-0500
Practice Address - Fax:276-666-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7547584OtherAETNA
VA610906400OtherOWCP-DOL
VA9960505OtherCIGNA
VA010098467Medicaid
VA249329OtherSOUTHERN HEALTH
VA146677OtherANTHEM BCBS
VA010098467Medicaid
VA010098467Medicaid