Healthcare Provider Details

I. General information

NPI: 1760559900
Provider Name (Legal Business Name): ALEXANDER G AVENIROV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 STERIGERE ST
NORRISTOWN PA
19401-5300
US

IV. Provider business mailing address

1 RIDGE RD
MALVERN PA
19355-2018
US

V. Phone/Fax

Practice location:
  • Phone: 610-313-5646
  • Fax: 619-313-1013
Mailing address:
  • Phone: 610-695-9475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberMD-035743-E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: