Provider Demographics
NPI:1922091339
Name:HNILICA, MARK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:HNILICA
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:190 KIMEL PARK DR STE 155
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-765-6637
Practice Address - Fax:336-765-6964
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35 082797207T00000X
NC9700588207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35 082797OtherSTATE LICENSE
NC891046YMedicaid
OH2437376Medicaid
NC891046YMedicaid
OH2437376Medicaid
NC2075432Medicare PIN