Provider Demographics
NPI:1982613196
Name:MARK, ALICE GRACE (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:GRACE
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 CENTRE ST
Mailing Address - Street 2:SOUTHERN JAMAICA PLAIN HEALTH CENTER
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2555
Mailing Address - Country:US
Mailing Address - Phone:617-983-4100
Mailing Address - Fax:
Practice Address - Street 1:640 CENTRE ST
Practice Address - Street 2:SOUTHERN JAMAICA PLAIN HEALTH CENTER
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2555
Practice Address - Country:US
Practice Address - Phone:617-983-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216999207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology