Basic Information
| Provider Information | |||||||||
| NPI: | 1356394837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCUTCHEON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 WEST CLINTON STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365452623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2512462350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5100 RANGELINE SERVICE RD N | ||||||||
| Address2: | TILLMAN'S CORNER | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366199504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513784000 | ||||||||
| FaxNumber: | 2513784006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11316 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C78586 | 01 | AL | UPIN | OTHER |