Healthcare Provider Details

I. General information

NPI: 1871755827
Provider Name (Legal Business Name): MAKSIM ROVENSKY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE J4-133
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

27020 CEDAR RD APT 707-1
BEACHWOOD OH
44122-1163
US

V. Phone/Fax

Practice location:
  • Phone: 216-445-6816
  • Fax:
Mailing address:
  • Phone: 917-705-5254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number010647
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number258499
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: