Provider Demographics
NPI:1043325657
Name:MIESZKALSKI, GLENN B
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:MIESZKALSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-231-8937
Mailing Address - Fax:717-231-8588
Practice Address - Street 1:4300 LONDONDERRY RD LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-724-6740
Practice Address - Fax:717-724-6741
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049823L207RH0003X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101107828Medicaid
PAF80710Medicare UPIN
PA083055Medicare ID - Type Unspecified