Healthcare Provider Details

I. General information

NPI: 1699689638
Provider Name (Legal Business Name): VASILIY KONNYKH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N 39TH ST
PHILADELPHIA PA
19104-2640
US

IV. Provider business mailing address

4055 RIDGE AVE APT 7407
PHILADELPHIA PA
19129-1596
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-8000
  • Fax:
Mailing address:
  • Phone: 610-755-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number739940
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: