Provider Demographics
NPI:1962476192
Name:MARK L. GRAVLEE, M.D., P.C.
Entity Type:Organization
Organization Name:MARK L. GRAVLEE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAVLEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-667-4991
Mailing Address - Street 1:11685 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4913
Mailing Address - Country:US
Mailing Address - Phone:770-667-4991
Mailing Address - Fax:770-667-4994
Practice Address - Street 1:11685 ALPHARETTA HWY
Practice Address - Street 2:SUITE 180
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4913
Practice Address - Country:US
Practice Address - Phone:770-667-4991
Practice Address - Fax:770-667-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34355208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD32746Medicare UPIN
GA02BDBPVMedicare ID - Type UnspecifiedDALTON OFFICE