Healthcare Provider Details

I. General information

NPI: 1518476167
Provider Name (Legal Business Name): IVAN MICHAEL REBEYKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST
RICHMOND VA
23219-1930
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-2467
  • Fax: 804-828-8559
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101262576
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: