Healthcare Provider Details

I. General information

NPI: 1407838642
Provider Name (Legal Business Name): MARK ALAN VINING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 09/20/2023
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF PEDIATRICS
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

UMASS MEMORIAL HEALTH 55 LAKE AVENUE NORTH
WORCESTER MA
01655
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-2853
  • Fax: 508-856-1042
Mailing address:
  • Phone: 774-442-5139
  • Fax: 774-443-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number205146
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: