Provider Demographics
NPI:1730188319
Name:GLOSS, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GLOSS
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:PO BOX 14928
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4044
Mailing Address - Country:US
Mailing Address - Phone:617-277-0939
Mailing Address - Fax:617-277-7138
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:STE 7B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-277-0939
Practice Address - Fax:617-277-7138
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2015-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1502772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3156281Medicaid
MAA22046Medicare ID - Type Unspecified