Healthcare Provider Details

I. General information

NPI: 1073597845
Provider Name (Legal Business Name): MARK BRUCKEL ELLIOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MAIN ST
STOCKBRIDGE MA
01262-0962
US

IV. Provider business mailing address

PO BOX 962
STOCKBRIDGE MA
01262-0962
US

V. Phone/Fax

Practice location:
  • Phone: 413-551-7925
  • Fax: 413-728-5580
Mailing address:
  • Phone: 413-551-7925
  • Fax: 413-728-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number218113
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: