Provider Demographics
NPI:1578562435
Name:MELNIKOV, ALEXANDER (PA)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:MELNIKOV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4307
Mailing Address - Country:US
Mailing Address - Phone:765-741-1411
Mailing Address - Fax:
Practice Address - Street 1:2015 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4337
Practice Address - Country:US
Practice Address - Phone:765-646-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFM0844868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340095OtherBLUE CROSS/BLUE SHIELD
IN970024419OtherRAILROAD MEDICARE
IN203170SSMedicare ID - Type Unspecified
IN000000340095OtherBLUE CROSS/BLUE SHIELD
INP37658Medicare UPIN