Healthcare Provider Details

I. General information

NPI: 1831740331
Provider Name (Legal Business Name): MARK HEBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-2100
  • Fax:
Mailing address:
  • Phone: 617-667-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11719
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberLP-0011103
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN10045268
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704273394
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: