Healthcare Provider Details

I. General information

NPI: 1508849969
Provider Name (Legal Business Name): MARK H MIROCHNICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 HARRISON AVE MENINO 3
BOSTON MA
02118-2905
US

IV. Provider business mailing address

720 HARRISON AVE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5471
  • Fax: 617-414-4358
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51072
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number51072
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: