Healthcare Provider Details

I. General information

NPI: 1962996876
Provider Name (Legal Business Name): ALEXANDRA DIANE HALUSKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA DIANE PITAWANAKWAT

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124-2203
US

IV. Provider business mailing address

6780 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124-2294
US

V. Phone/Fax

Practice location:
  • Phone: 440-312-4500
  • Fax:
Mailing address:
  • Phone: 440-312-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4351044680
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.145057
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: