Basic Information
| Provider Information | |||||||||
| NPI: | 1962493361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECHTEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 531797 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303531797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435243344 | ||||||||
| FaxNumber: | 8442959894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TL996 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2006-00859 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1962493361 | 05 | NC | MEDICAID | 009966 | 05 | SC | MEDICAID | P00349261 | 01 | SC | RAILROAD MEDICARE | OTHER |