1699575704 NPI number — MADISON ROSE DENTON SHEVCHENKO PA

Table of content: MADISON ROSE DENTON SHEVCHENKO PA (NPI 1699575704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699575704 NPI number — MADISON ROSE DENTON SHEVCHENKO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEVCHENKO
Provider First Name:
MADISON
Provider Middle Name:
ROSE DENTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DENTON
Provider Other First Name:
MADISON
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699575704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3055 ALVARADO ST STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LEANDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94577-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-969-4253
Provider Business Mailing Address Fax Number:
510-550-3686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3055 ALVARADO ST STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LEANDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94577-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-969-4253
Provider Business Practice Location Address Fax Number:
510-550-3686
Provider Enumeration Date:
03/17/2025

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: 363A00000X , with the licence number:  PA66060 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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