MEDICARE: MR. ILYA BEYDER

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	332B00000X	Durable Medical Equipment & Medical Supplies		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	87-078373	OTHER	WI	MEDICAL SUPPY

General Provider Information

NPI Number	:	1790873602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ILYA BEYDER

Provider Business Mailing Address
First Line	:	8023 W NATIONAL AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-4507
Country	:	US
Telephone Number	:	414-302-6337
Fax Number	:	414-755-2039

Provider Business Practice Location Address
First Line	:	8023 W NATIONAL AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-4507
Country	:	US
Telephone Number	:	414-302-6337
Fax Number	:	414-755-2039

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	12/18/2007

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Directions to “ MR. ILYA BEYDER ” Practice Location

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