Provider Demographics
NPI:1952574550
Name:J MARK GRESHAM MD PC
Entity Type:Organization
Organization Name:J MARK GRESHAM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-437-0770
Mailing Address - Street 1:301 JONES AVE
Mailing Address - Street 2:P O BOX 328
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1510
Mailing Address - Country:US
Mailing Address - Phone:706-437-0770
Mailing Address - Fax:706-437-0540
Practice Address - Street 1:301 JONES AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-1510
Practice Address - Country:US
Practice Address - Phone:706-437-0770
Practice Address - Fax:706-437-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039358207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700386Medicare PIN