Healthcare Provider Details

I. General information

NPI: 1588649214
Provider Name (Legal Business Name): YURI O SHEVCHENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5520
  • Fax:
Mailing address:
  • Phone: 484-628-1324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD059395L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberMD059395L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: