Provider Demographics
NPI:1689655094
Name:GEBHARDT, MARK CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CLYDE
Last Name:GEBHARDT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:BIDMC - STONEMAN 10
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-2140
Mailing Address - Fax:617-667-0227
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:BIDMC - STONEMAN 10
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-2140
Practice Address - Fax:617-667-0227
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA47866207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE05505OtherBCBS MA
MA0142379Medicaid
MA047866OtherTUFTS HEALTH PLAN
MA0142379Medicaid
MA047866OtherTUFTS HEALTH PLAN