Healthcare Provider Details

I. General information

NPI: 1548241904
Provider Name (Legal Business Name): PAVEL L KHIMENKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 HOSPITAL ST SUITE 107
PASCAGOULA MS
39581-5310
US

IV. Provider business mailing address

4211 HOSPITAL ST SUITE 107
PASCAGOULA MS
39581-5310
US

V. Phone/Fax

Practice location:
  • Phone: 228-202-3335
  • Fax: 228-202-3337
Mailing address:
  • Phone: 228-202-3335
  • Fax: 228-202-3337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18035
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: