Provider Demographics
NPI:1568599140
Name:HILDEBRAND, MARK STEVEN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:HILDEBRAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3257
Mailing Address - Country:US
Mailing Address - Phone:802-747-6394
Mailing Address - Fax:802-747-9073
Practice Address - Street 1:87 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3257
Practice Address - Country:US
Practice Address - Phone:802-747-6394
Practice Address - Fax:802-747-9073
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007968Medicaid
VTVN2597Medicare ID - Type Unspecified
VT1007968Medicaid