MEDICARE: ANDREY GVOZDEVSKIY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1255487153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREY GVOZDEVSKIY

Provider Business Mailing Address
First Line	:	2409 RAYNOR CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-6860
Country	:	US
Telephone Number	:	757-471-6215
Fax Number	:

Provider Business Practice Location Address
First Line	:	609 LYNNHAVEN PKWY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-7336
Country	:	US
Telephone Number	:	757-431-6617
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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