Healthcare Provider Details

I. General information

NPI: 1013989573
Provider Name (Legal Business Name): YELENA GERASHCHENKO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64442
BALTIMORE MD
21264-4442
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-8000
  • Fax:
Mailing address:
  • Phone: 410-225-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002763
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: