1679987879 NPI number — ALEXANDRE DEREVIANKO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679987879 NPI number — ALEXANDRE DEREVIANKO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEREVIANKO
Provider First Name:
ALEXANDRE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1679987879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1811 ARKANSAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT LAKES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60088-4244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-480-9807
Provider Business Mailing Address Fax Number:
847-733-5827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 ARKANSAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088-4244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-480-9807
Provider Business Practice Location Address Fax Number:
847-733-5827
Provider Enumeration Date:
06/16/2014

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: 246ZC0007X , with the licence number:  238000408 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 238000408 . This is a "LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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