Basic Information
| Provider Information | |||||||||
| NPI: | 1114904679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLENS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1022 1ST ST N | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ALABASTER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350078706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056635775 | ||||||||
| FaxNumber: | 2056642112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1022 1ST ST N | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ALABASTER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350078706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056635775 | ||||||||
| FaxNumber: | 2056642112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 20944 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 009994255 | 05 | AL | MEDICAID |