Provider Demographics
NPI:1255447967
Name:MARK J. EISEN, M.D.
Entity type:Organization
Organization Name:MARK J. EISEN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:W
Authorized Official - Last Name:GILLIKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:252-353-7162
Mailing Address - Street 1:PO BOX 30696
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0696
Mailing Address - Country:US
Mailing Address - Phone:252-353-7162
Mailing Address - Fax:252-353-1760
Practice Address - Street 1:900 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUTIE A
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2601
Practice Address - Country:US
Practice Address - Phone:919-967-3452
Practice Address - Fax:919-932-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930263Medicaid
NC202952Medicare ID - Type UnspecifiedGROUP
NC8930263Medicaid