Provider Demographics
NPI:1942404504
Name:TICOLA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TICOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1801
Practice Address - Country:US
Practice Address - Phone:800-822-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.26649207R00000X
FLME99295207R00000X
AL26649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 99295OtherSTATE LICENSE NUMBER
FL278827600Medicaid
AL130700Medicaid
AF641WMedicare PIN
AL102I118568Medicare PIN