Basic Information
| Provider Information | |||||||||
| NPI: | 1891729232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYCYK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 414402 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987138 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL | ||||||||
| Address2: | DOWLING 1 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036102179 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PT0002X | 036-102179 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | 157362 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.