Healthcare Provider Details

I. General information

NPI: 1821674763
Provider Name (Legal Business Name): MARK LEVINE MD, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 617-410-4534
  • Fax:
Mailing address:
  • Phone: 404-778-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number1021992
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1021992
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number1021992
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: