Provider Demographics
NPI:1205034196
Name:WESLEY, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:WESLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHILDREN'S HOSPITAL BOSTON, 300 LONGWOOD AVE
Mailing Address - Street 2:DIVISION OF CARDIAC ANESTHESIA
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-6225
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S HOSPITAL BOSTON, 300 LONGWOOD AVE
Practice Address - Street 2:DIVISION OF CARDIAC ANESTHESIA
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-355-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232274207L00000X
FLME75926207L00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254122000Medicaid
FL43514YMedicare PIN