Basic Information
Provider Information | |||||||||
NPI: | 1154346393 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHVACHUK | ||||||||
FirstName: | IVAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1462 ERIE BLVD | ||||||||
Address2: | SUITE 2 | ||||||||
City: | SCHENECTADY | ||||||||
State: | NY | ||||||||
PostalCode: | 123051026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1101 NOTT ST | ||||||||
Address2: |   | ||||||||
City: | SCHENECTADY | ||||||||
State: | NY | ||||||||
PostalCode: | 123082425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182434000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 240695 | NY | X |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | 240695 | NY | X |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 10115093 | 01 | NY | CDPHP | OTHER | 000411953001 | 01 | NY | BSNENY | OTHER | 11568824 | 01 |   | CAQH | OTHER | 4149461 | 01 | NY | MVP | OTHER | 070209000089 | 01 | NY | FIDELIS CARE | OTHER | 240SD1 | 01 | NY | BLUE CROSS | OTHER |