1528018751 NPI number — GREGORY C MIECKOWSKI M.D.

Table of content: GREGORY C MIECKOWSKI M.D. (NPI 1528018751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528018751 NPI number — GREGORY C MIECKOWSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIECKOWSKI
Provider First Name:
GREGORY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528018751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16830-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-765-7314
Provider Business Mailing Address Fax Number:
814-339-6165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 TURNPIKE AVE
Provider Second Line Business Practice Location Address:
IMAGING DEPARTMENT
Provider Business Practice Location Address City Name:
CLEARFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16830-1232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-765-7314
Provider Business Practice Location Address Fax Number:
814-339-6165
Provider Enumeration Date:
05/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085B0100X , with the licence number: MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X , with the licence number: MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: MD026705E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300135692 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0009876470004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 026156 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".