Healthcare Provider Details

I. General information

NPI: 1891729232
Provider Name (Legal Business Name): MARK B. MYCYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CTR PL DOWLING 1 SOUTH
BOSTON MA
02118-2908
US

IV. Provider business mailing address

PO BOX 414402
BOSTON MA
02241-0001
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8000
  • Fax:
Mailing address:
  • Phone: 866-898-7138
  • Fax: 616-975-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036102179
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number036-102179
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number157362
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: