Healthcare Provider Details

I. General information

NPI: 1528018751
Provider Name (Legal Business Name): GREGORY C MIECKOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 TURNPIKE AVE IMAGING DEPARTMENT
CLEARFIELD PA
16830-1232
US

IV. Provider business mailing address

PO BOX 129
CLEARFIELD PA
16830-0129
US

V. Phone/Fax

Practice location:
  • Phone: 814-765-7314
  • Fax: 814-339-6165
Mailing address:
  • Phone: 814-765-7314
  • Fax: 814-339-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD026705E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD026705E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD026705E
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD026705E
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD026705E
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberMD026705E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: