Provider Demographics
NPI:1598732281
Name:RADZICKI, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:RADZICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:354 BIRNIE AVE
Mailing Address - Street 2:HAMPDEN COUNTY PHYSICIAN ASSOCIATES
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1108
Mailing Address - Country:US
Mailing Address - Phone:413-733-3470
Mailing Address - Fax:413-733-5235
Practice Address - Street 1:77 BOYLSTON STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-734-8254
Practice Address - Fax:413-747-5870
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA40489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA30013000Medicaid
110208456Medicare PIN
MAN51703Medicare PIN
MAA68089Medicare UPIN