Basic Information
Provider Information | |||||||||
NPI: | 1366421612 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALVAGGIO | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 MEDICAL PARK DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280250939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7047861108 | ||||||||
FaxNumber: | 7047821826 | ||||||||
Practice Location | |||||||||
Address1: | 200 MEDICAL PARK DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280250939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7047861108 | ||||||||
FaxNumber: | 7047821826 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2006 | ||||||||
LastUpdateDate: | 08/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101238654 | VA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 010195390 | 05 | VA |   | MEDICAID | 183841 | 01 | VA | ANTHEM | OTHER |