Healthcare Provider Details

I. General information

NPI: 1316197080
Provider Name (Legal Business Name): GLEN RICHARD MISKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 THREE SPRINGS DR STE 5A
WEIRTON WV
26062-3839
US

IV. Provider business mailing address

PO BOX 645532
PITTSBURGH PA
15264-5253
US

V. Phone/Fax

Practice location:
  • Phone: 740-792-4220
  • Fax: 740-275-4472
Mailing address:
  • Phone: 740-792-4220
  • Fax: 740-275-4472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberOS-010883-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: