Basic Information
Provider Information | |||||||||
NPI: | 1356488761 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9247 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319089247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063227884 | ||||||||
FaxNumber: | 7062432027 | ||||||||
Practice Location | |||||||||
Address1: | 3465 MACON RD | ||||||||
Address2: | STE D | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319072582 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062433051 | ||||||||
FaxNumber: | 7062432027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2007 | ||||||||
LastUpdateDate: | 05/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002938 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 174759447A | 05 | GA |   | MEDICAID | 100001639C | 05 | GA |   | MEDICAID | 970009967 | 01 | GA | RAIL ROAD MEDICARE | OTHER | 202I975249 | 01 | GA | MEDICARE PTAN | OTHER |