Healthcare Provider Details

I. General information

NPI: 1467763581
Provider Name (Legal Business Name): MIRANDA SWADOS BALKIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 OLD NORTH RD
WORTHINGTON MA
01098-9753
US

IV. Provider business mailing address

58 OLD NORTH RD
WORTHINGTON MA
01098-9753
US

V. Phone/Fax

Practice location:
  • Phone: 413-238-5511
  • Fax: 413-238-5358
Mailing address:
  • Phone: 413-238-5511
  • Fax: 413-238-5358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number254019
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: