NPIMap

Individual provider Active NPI

Mark L Douglas, DO

  • Internal Medicine Physician
  • Cross Lanes, WV
National Provider Identifier
1306974464
Registry record updated Dec 31, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
1390 Issued in WV
Practice address
5098 West Washington St
Ste 408
Cross Lanes, WV 25313-1419
Phone
(304) 776-5594
Fax
(304) 776-3521
NPI assigned
Mar 1, 2007
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 31, 2012

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 1390 WV Primary

Addresses

Primary practice location

5098 West Washington St
Ste 408
Cross Lanes, WV 25313-1419

Mailing address

5098 West Washington St
Ste 408
Cross Lanes, WV 25313-1419
Phone (304) 776-5594

Other identifiers 4

IdentifierTypeStateIssuer
001722523OtherWVBLUE CROSS BLUE SHIELD
0839644OtherWVMEDICARE PIN
4333567OtherWVAETNA
550773123OtherWVTAX ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20120302000016 WV Practitioner - Internal Medicine 0941114631 Practice locations: Cross Lanes, WV

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
West Virginia School of Osteopathic Medicine, 1989
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

5098 W Washington St
Suite 408
Cross Lanes, WV 25313-1561

5098 Washington St W
Suite 408
Charleston, WV 25313-1561

Hospital & facility affiliations

  • Charleston Area Medical Center Hospital, Charleston, WV, CCN 510022
  • Thomas Memorial Hospital Hospital, South Charleston, WV, CCN 510029

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
1390WVMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Mark L. Douglas, DO Internal Medicine PastSince Nov 6, 2000 Accepting new patients
Maxwell Eyecare Center, Inc PastSince Oct 10, 2009 Accepting new patients

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/8270/brand/1/csg/1/fhir/r4

Organizations & group practices 2

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

Hospital & facility affiliations 12

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

NPI Registry JSON

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

{
    "created_epoch": "1172707200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1356912000000",
    "number": "1306974464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5098 WEST WASHINGTON ST",
            "address_2": "STE 408",
            "city": "CROSS LANES",
            "state": "WV",
            "postal_code": "253131419",
            "telephone_number": "304-776-5594",
            "fax_number": "304-776-3521"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5098 WEST WASHINGTON ST",
            "address_2": "STE 408",
            "city": "CROSS LANES",
            "state": "WV",
            "postal_code": "253131419",
            "telephone_number": "304-776-5594",
            "fax_number": "304-776-3521"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOUGLAS",
        "first_name": "MARK",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-03-01",
        "last_updated": "2012-12-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "WV",
            "license": "1390",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "001722523",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PIN",
            "identifier": "0839644",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "4333567",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAX ID",
            "identifier": "550773123",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cross Lanes, WV

Sources for this page

Verify at the official NPI Registry.