Healthcare Provider Details

I. General information

NPI: 1124249735
Provider Name (Legal Business Name): MICHAEL BLAZEJ PRZYDZIELSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 CLINTON ST
CONCORD NH
03301-2359
US

IV. Provider business mailing address

12 RAYTON RD
HANOVER NH
03755-2214
US

V. Phone/Fax

Practice location:
  • Phone: 603-271-5300
  • Fax:
Mailing address:
  • Phone: 603-727-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number15847
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0420012022
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15847
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0420012022
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: