1598782088 NPI number — ALEXANDER SKAVYSH M.D.

Table of content: ALEXANDER SKAVYSH M.D. (NPI 1598782088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598782088 NPI number — ALEXANDER SKAVYSH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKAVYSH
Provider First Name:
ALEXANDER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1598782088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E MILLER DR APT 87
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47401-6572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-343-2253
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 JOHN R WOODEN DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46151-1863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-342-5415
Provider Business Practice Location Address Fax Number:
765-342-3415
Provider Enumeration Date:
07/17/2006

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: 208600000X , with the licence number:  01062091A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: MD2010-0754 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 042-0012180 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200823150 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200377200 . This is a "GROUP MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1104827633 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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