Provider Demographics
NPI:1578549010
Name:BUCKBERG, MIRIAM S (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:S
Last Name:BUCKBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:S
Other - Last Name:SHADOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:701 ENFIELD STREET
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-6058
Practice Address - Fax:860-253-9326
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070556207Q00000X
ME017423207Q00000X
CT64731207R00000X
MA251720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2046637Medicaid
MEAA99889OtherHPHC
ME099883OtherANTHEM ME
ME432710699Medicaid
OH080189297OtherRAILROAD MEDICARE NUMBER
ME432710699Medicaid
MEAA99889OtherHPHC