Healthcare Provider Details

I. General information

NPI: 1487698072
Provider Name (Legal Business Name): GENNADY P CHERNYAK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 WEST ROYALE DRIVE DERMATOLOGY CLINIC OF MUNCIE, INC.
MUNCIE IN
47304-2243
US

IV. Provider business mailing address

1808 WEST ROYALE DRIVE DERMATOLOGY CLINIC OF MUNCIE, INC.
MUNCIE IN
47304-2243
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-8188
  • Fax: 765-282-7242
Mailing address:
  • Phone: 765-288-8188
  • Fax: 765-282-7242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000699A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: