Basic Information
| Provider Information | |||||||||
| NPI: | 1164404976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANNETTONI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | ECU PHYSICIANS | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 HEART DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278348982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527444400 | ||||||||
| FaxNumber: | 2527443987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 35447 | IA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208600000X | 2014-01742 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1164404976 | 05 | NC | MEDICAID | 36310 | 01 | IA | WELLMARK BCBS | OTHER | 0432120 | 05 | IA | MEDICAID | 188J9 | 01 | NC | BCBS NC | OTHER |