=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669032363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MSN CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2019
-----------------------------------------------------
Last Update Date | 08/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9330 W LINCOLN AVE STE 10
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-366-2985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12507 N EMILY LN
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-915-6255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. VYACHESLAV DUBROVSKY
-----------------------------------------------------
Credential | APNP BC
-----------------------------------------------------
Telephone | 414-915-6255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------