Provider Demographics
NPI:1598782088
Name:SKAVYSH, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:SKAVYSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MILLER DR APT 87
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6572
Mailing Address - Country:US
Mailing Address - Phone:765-343-2253
Mailing Address - Fax:
Practice Address - Street 1:2200 JOHN R WOODEN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1863
Practice Address - Country:US
Practice Address - Phone:765-342-5415
Practice Address - Fax:765-342-3415
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062091A208600000X
NMMD2010-0754208600000X
VT042-0012180208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200823150Medicaid
IN200377200OtherGROUP MEDICAID
IN1104827633OtherGROUP NPI NUMBER
IN200377200OtherGROUP MEDICAID
INI61966Medicare UPIN
IN191430HMedicare PIN