Healthcare Provider Details

I. General information

NPI: 1417863960
Provider Name (Legal Business Name): MARY C BURKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 FORDHAM RD
BOSTON MA
02134-3000
US

IV. Provider business mailing address

1516 MYSTIC VALLEY PKWY UNIT 2
MEDFORD MA
02155-6808
US

V. Phone/Fax

Practice location:
  • Phone: 617-782-6460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: