Individual
MARK ANTHONY MICOLUCCI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
9 MCELHANEY RD, TRAVELERS REST, SC 29690-1734
(864) 834-3192
(864) 241-9234
Mailing address
300 E MCBEE AVE FL 4, GREENVILLE, SC 29601-2842
(864) 695-6065
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
52497
SC
390200000X
Student in an Organized Health Care Education/Training Program
LL52497
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LL52497
STATE
SC
Enumeration date
06/15/2018
Last updated
08/31/2021
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