Healthcare Provider Details

I. General information

NPI: 1366412017
Provider Name (Legal Business Name): MARTIN HERTL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 543
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTON MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3664
  • Fax: 617-724-5993
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number042.0012780
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number219964
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: