Provider Demographics
NPI:1205816576
Name:BRUCE SHICKMANTER, MD, PC
Entity Type:Organization
Organization Name:BRUCE SHICKMANTER, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHICKMANTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-499-8515
Mailing Address - Street 1:777 NORTH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4147
Mailing Address - Country:US
Mailing Address - Phone:413-499-8515
Mailing Address - Fax:413-442-9161
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-499-8515
Practice Address - Fax:413-442-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703641Medicaid
MAM17611OtherBCBSMA
NY7768OtherCDPHP
MAM17611OtherBCBSMA
D82851Medicare UPIN