Provider Demographics
NPI:1770572273
Name:DISIENA, MICHAEL ROSS (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROSS
Last Name:DISIENA
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:777 NORTH ST
Mailing Address - Street 2:PO BOX 1677
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01202-1677
Mailing Address - Country:US
Mailing Address - Phone:413-445-6420
Mailing Address - Fax:413-499-4907
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-445-6420
Practice Address - Fax:413-499-4907
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2007-09-26
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Provider Licenses
StateLicense IDTaxonomies
MA1550502086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2107775Medicaid
MA2107775Medicaid
A38936Medicare PIN