MEDICARE: DR. ALEXEI MIKHAILOVICH PRYTKOV M.D, PHD

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	207P00000X	Emergency Medicine Physician	ME123293	FL
2	207Q00000X	Family Medicine Physician	ME123293	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	UJG97	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1629022157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXEI MIKHAILOVICH PRYTKOV M.D, PHD

Provider Business Mailing Address
First Line	:	10870 US ONE N UNIT 104
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-7804
Country	:	US
Telephone Number	:	904-438-2720
Fax Number	:	904-212-1711

Provider Business Practice Location Address
First Line	:	10870 US ONE N UNIT 104
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-7804
Country	:	US
Telephone Number	:	904-438-2720
Fax Number	:	904-212-1711

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/27/2020

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