Basic Information
| Provider Information | |||||||||
| NPI: | 1831313378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 COLBY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106660854 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 COLBY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106660854 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A91492 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | A91492 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | A91492 | CA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1831313378 | 05 | CA | MEDICAID |