=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780650960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SASA ZIVKOVIC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2006
-----------------------------------------------------
Last Update Date | 06/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 BOSTON POST RD
-----------------------------------------------------
City | GUILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06437-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-925-3637
-----------------------------------------------------
Fax | 877-925-3329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3471 5TH AVE SUITE 810 LKB
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15213-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | 70709
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------