Provider Demographics
NPI:1619993946
Name:RADIONTCHENKO, ALEXEI (MD)
Entity Type:Individual
Prefix:
First Name:ALEXEI
Middle Name:
Last Name:RADIONTCHENKO
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-993-8181
Mailing Address - Fax:336-996-9539
Practice Address - Street 1:291 BROAD ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2932
Practice Address - Country:US
Practice Address - Phone:336-993-8181
Practice Address - Fax:336-996-9539
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1189COtherBCBS - CATAWBA
NCG91367OtherUPIN
NC891189CMedicaid
NC891189CMedicaid
NCBR6189636OtherDEA - NC
NC1189COtherBCBS - CATAWBA