Healthcare Provider Details

I. General information

NPI: 1063412344
Provider Name (Legal Business Name): GLENN E MISKOVSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 HALL DR AMHERST MEDICAL CENTER
AMHERST MA
01002-2751
US

IV. Provider business mailing address

31 HALL DR AMHERST MEDICAL CENTER
AMHERST MA
01002-2751
US

V. Phone/Fax

Practice location:
  • Phone: 413-256-8561
  • Fax: 413-256-4421
Mailing address:
  • Phone: 413-256-8561
  • Fax: 413-256-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number207711
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: