Healthcare Provider Details

I. General information

NPI: 1306845672
Provider Name (Legal Business Name): YELENA MIKICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MAIN ST STE 302
SPRINGFIELD MA
01107-1088
US

IV. Provider business mailing address

3550 MAIN ST STE 302
SPRINGFIELD MA
01107-1088
US

V. Phone/Fax

Practice location:
  • Phone: 413-781-8290
  • Fax: 413-737-8540
Mailing address:
  • Phone: 413-781-8290
  • Fax: 413-732-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number154223
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: