Provider Demographics
NPI:1033292974
Name:HAMILL, MARK EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:HAMILL
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 1:1906 BELLEVIEW AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1838
Mailing Address - Country:US
Mailing Address - Phone:540-981-7434
Mailing Address - Fax:540-981-8681
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7434
Practice Address - Fax:540-981-8681
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248905208600000X, 2086S0127X, 2086S0102X
VA01012500692086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV3485AOtherMEDICARE PTAN
NY03037941Medicaid
NYP00721655Medicare PIN
NYJ400001054Medicare PIN