Provider Demographics
NPI:1942248232
Name:BERENSON, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:BERENSON
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 1:405 PEARL ST
Mailing Address - Street 2:NORTH SUBURBAN ORTHO ASSOC
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:781-665-9500
Mailing Address - Fax:
Practice Address - Street 1:721 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-620-0198
Practice Address - Fax:781-620-0108
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32420207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA200036492OtherPALMETTO GBA
MA0178551Medicaid
MAA53831Medicare UPIN
MA200036492OtherPALMETTO GBA