Basic Information
| Provider Information | |||||||||
| NPI: | 1528018751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIECKOWSKI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168300129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147657314 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 TURNPIKE AVE | ||||||||
| Address2: | IMAGING DEPARTMENT | ||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147657314 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD026705E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | MD026705E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | MD026705E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | MD026705E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | MD026705E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | MD026705E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 300135692 | 01 | RR MEDICARE | OTHER | 0009876470004 | 05 | PA | MEDICAID | 026156 | 01 | PA | HIGHMARK | OTHER |