Provider Demographics
NPI:1134191828
Name:PIASECKI, PHILIP S (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:S
Last Name:PIASECKI
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 1:2055 NORMANDIE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-269-6337
Mailing Address - Fax:334-834-0657
Practice Address - Street 1:2055 NORMANDIE DR
Practice Address - Street 2:108
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2732
Practice Address - Country:US
Practice Address - Phone:334-288-4624
Practice Address - Fax:334-280-3628
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000249812085R0202X
FLME836272085R0202X
GA0572342085R0202X
AL249812085R0204X
ALMD 249812085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL108113Medicaid
AL108382Medicaid
AL106977Medicaid
AL106979Medicaid
000058867Medicare PIN
000058866Medicare PIN
051515710Medicare PIN
H92061Medicare UPIN
AL106977Medicaid
AL106979Medicaid
051515703Medicare PIN