Provider Demographics
NPI:1013916295
Name:ALLEY, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:ALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 535744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-5510
Mailing Address - Country:US
Mailing Address - Phone:844-294-5114
Mailing Address - Fax:865-691-0843
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 5-B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-3460
Practice Address - Fax:423-224-3465
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN20227207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3061778Medicaid
3037574OtherBS OF TN
00013859OtherNHC CARE ADMIN.
TN100011088Medicaid
NC5900346Medicaid
TN0100OtherJOHN DEERE
064423OtherANTHEM BCBS
VA005749221Medicaid
064423OtherANTHEM BCBS
TN100011088Medicaid
TN3061779Medicare PIN
WV20000254000Medicaid
TN100011088Medicaid