Provider Demographics
NPI:1528018751
Name:MIECKOWSKI, GREGORY C (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:MIECKOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-0129
Mailing Address - Country:US
Mailing Address - Phone:814-765-7314
Mailing Address - Fax:814-339-6165
Practice Address - Street 1:809 TURNPIKE AVE
Practice Address - Street 2:IMAGING DEPARTMENT
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-1232
Practice Address - Country:US
Practice Address - Phone:814-765-7314
Practice Address - Fax:814-339-6165
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026705E2085R0202X, 2085B0100X, 2085N0904X, 2085P0229X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
300135692OtherRR MEDICARE
PA0009876470004Medicaid
PA026156OtherHIGHMARK
B33558Medicare UPIN
026156Medicare PIN
300135692OtherRR MEDICARE