Provider Demographics
NPI:1740450220
Name:INNIS, MARK AINSLEY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:AINSLEY
Last Name:INNIS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:865-985-7012
Mailing Address - Fax:865-985-7077
Practice Address - Street 1:3636 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3236
Practice Address - Country:US
Practice Address - Phone:757-398-2200
Practice Address - Fax:757-398-2359
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2021-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY248590207P00000X
VA0101243430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740450220Medicaid
VAMC10479Medicare PIN