Provider Demographics
NPI:1497957468
Name:NERSESYAN, HRACHYA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:HRACHYA
Middle Name:
Last Name:NERSESYAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NE RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1919
Mailing Address - Country:US
Mailing Address - Phone:309-624-8500
Mailing Address - Fax:
Practice Address - Street 1:100 NE RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1919
Practice Address - Country:US
Practice Address - Phone:309-624-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-0488192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IL809840OtherMEDICARE GROUP PTAN