Healthcare Provider Details

I. General information

NPI: 1114280310
Provider Name (Legal Business Name): MARK STOLTENBERG M.D., M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST FOUNDERS OFFICE 600
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT STREET FOUNDERS OFFICE 600
BOSTON, MA 02114 MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-3596
  • Fax:
Mailing address:
  • Phone: 617-643-3596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number1053657270
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number266959
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: