Provider Demographics
NPI:1740208560
Name:HEDBERG, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HEDBERG
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 1:220 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1210
Mailing Address - Country:US
Mailing Address - Phone:317-776-1061
Mailing Address - Fax:317-776-1172
Practice Address - Street 1:220 LAKEVIEW DR STE 14
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1210
Practice Address - Country:US
Practice Address - Phone:317-776-1061
Practice Address - Fax:317-776-1172
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012730A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200010295Medicaid