Provider Demographics
NPI:1548257496
Name:HALISTA, SCOTT M (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:HALISTA
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 1:3377 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1111
Mailing Address - Country:US
Mailing Address - Phone:413-734-5661
Mailing Address - Fax:
Practice Address - Street 1:3377 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1111
Practice Address - Country:US
Practice Address - Phone:413-734-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75526207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF21661OtherUPIN MEDICARE PREVIOUS
MA3089193Medicaid
MAGX3085Medicare UPIN
MA3089193Medicaid