=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114125176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAVYN SKORUPAN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 04/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 WYOMING ST
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-272-9837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 WISTERIA DR
-----------------------------------------------------
City | OAKWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45419-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-272-9837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | OS014318
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------