Provider Demographics
NPI:1174579379
Name:MILES, MARK L (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 REIDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5643
Mailing Address - Country:US
Mailing Address - Phone:864-576-9201
Mailing Address - Fax:864-576-6584
Practice Address - Street 1:3021 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5643
Practice Address - Country:US
Practice Address - Phone:864-576-9201
Practice Address - Fax:864-576-6584
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4988OtherMEDICAID GROUP NO.
SCI90885Medicaid
GAP00386836OtherMEDICARE RAILROAD PTAN#
SCI90885Medicaid
SC8688Medicare PIN
SC9105Medicare PIN
GAP00386836OtherMEDICARE RAILROAD PTAN#