Provider Demographics
NPI:1265402325
Name:SHICKMANTER, BRUCE J (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:SHICKMANTER
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 1:777 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
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA773735OtherTUFTS HEALTHPLAN
MA2071711Medicaid
MAI22260OtherBCBSMA
NY10034408OtherCDPHP
NY00536214Medicaid
MA16388OtherHEALTH NEW ENGLAND
NY833694OtherMVP
MAD82851OtherHARVARD PILGRIM HEALTHCAR
MAD82851OtherHARVARD PILGRIM HEALTHCAR
MA16388OtherHEALTH NEW ENGLAND