Healthcare Provider Details

I. General information

NPI: 1356534895
Provider Name (Legal Business Name): ANDREJ LYSHCHIK M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH ST SUITE 3390
PHILADELPHIA PA
19107-4824
US

IV. Provider business mailing address

111 S 11TH ST SUITE 3390
PHILADELPHIA PA
19107-4824
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6226
  • Fax: 215-923-1562
Mailing address:
  • Phone: 215-955-6226
  • Fax: 215-923-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD445598
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD445598
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number46419
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: