=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578397816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MIKHAEAL DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2024
-----------------------------------------------------
Last Update Date | 08/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 N MEADOWS RD
-----------------------------------------------------
City | MEDFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02052-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-359-9119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 CEDAR ST STE 100
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-3527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 27751
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------