1295787133 NPI number — MR. ALEXANDER BRAZALOVICH DO

Table of content: MR. ALEXANDER BRAZALOVICH DO (NPI 1295787133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295787133 NPI number — MR. ALEXANDER BRAZALOVICH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAZALOVICH
Provider First Name:
ALEXANDER
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295787133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 DOUGLAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACO
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04072-9732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-283-2842
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 MAIN ST
Provider Second Line Business Practice Location Address:
MASSABESIC REGIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
WATERBORO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04087-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-247-6131
Provider Business Practice Location Address Fax Number:
207-247-6675
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1364 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1364 . This is a "LICENSE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 7659431002 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: MN3424 . This is a "HARVARD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 037872 . This is a "BCBS START NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 285210099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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