Individual
MARK WILLIAM MEMOLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
620 SUMMIT CROSSING PL, STE 106, GASTONIA, NC 28054
(704) 867-8021
(704) 864-4606
Mailing address
620 SUMMIT CROSSING PL, STE 106, GASTONIA, NC 28054
(704) 867-8021
(704) 864-4606
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
33274
NC
2085R0204X
Vascular & Interventional Radiology Physician
33274
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12402
PARTNERS
—
01
—
1642996
UNITED HEALTHCARE
—
01
—
2353109
AETNA HMO
—
01
—
300061402
RAILROAD MEDICARE
—
01
—
4630736
AETNA PPO
—
01
—
58609
BLUE CROSS BLUE SHIELD
—
01
—
73411
MEDCOST
—
05
—
8958609
—
NC
05
—
N33274
—
SC
Enumeration date
11/25/2005
Last updated
08/23/2010
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