L Mark Gustafson, M.D.

Primary specialty

Otolaryngology PhysicianTaxonomy code 207Y00000X

License

049795 Issued in GA

Practice address

150 Clinic Ave
Suite 201
Carrollton, GA 30117-4401

Phone

(770) 832-1488

NPI assigned

Jun 11, 2006

Last updated

Jul 18, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Otolaryngology

Education

Other, 1996

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Tanner Medical Group IncGroup PAC ID 2769536143, 120 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Tanner Medical Center - Carrollton Hospital, Carrollton, GA, CCN 110011

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: lmgustafson@carrolltonent.gwaydirect.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Tanner Medical Group Inc

  • Cardiovascular Disease Physician
  • Carrollton, GA
  • NPI 1396979787
  Medicare reassignment Care Compare group NPD
• Carrollton Ear, Nose and Throat, P.C.

  • Otolaryngology Physician
  • Carrollton, GA
  • NPI 1760410401
  Medicare reassignment NPD
• TMC Children's Healthcare of West Georgia

  • Medical Specialty Clinic/Center
  • Carrollton, GA
  • NPI 1518972348
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Tanner Medical Center, Inc

  dba Tanner Health System

  • General Acute Care Hospital
  • Carrollton, GA
  • NPI 1801883780
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149984000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658102400000",
    "number": "1073555629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 CLINIC AVE",
            "address_2": "SUITE 201",
            "city": "CARROLLTON",
            "state": "GA",
            "postal_code": "301174401",
            "telephone_number": "770-832-1488"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 CLINIC AVE",
            "address_2": "SUITE 201",
            "city": "CARROLLTON",
            "state": "GA",
            "postal_code": "301174401",
            "telephone_number": "770-832-1488"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUSTAFSON",
        "first_name": "L",
        "middle_name": "MARK",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-11",
        "last_updated": "2022-07-18",
        "certification_date": "2022-07-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "GA",
            "license": "049795",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00906463B",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS CLUE SHIELD",
            "identifier": "841043",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00906463C",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jill Megan Grilliot, MD
• Tracy R Grissett, P.T
• DL Griswold
• Joshua William Theodore Grubb, LPC
• Nicole A Gurbal, O.D.
• Austin Haedicke, LPC, CPCS, CCC, PN1
• Holley V. Hagan, NP-C
• Kristi Haisler, PMHNP
• Brett Alexander Hall, FNP
• Demoines Trevon Ham

• Otolaryngology Physician in Carrollton, GA
• Providers in Carrollton, GA by specialty
• Otolaryngology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.