Provider Demographics
NPI:1639278591
Name:SEVRUKOV, ALEXANDER B (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:B
Last Name:SEVRUKOV
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 1:132 S 10TH ST STE 3390
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5244
Mailing Address - Country:US
Mailing Address - Phone:800-858-1662
Mailing Address - Fax:215-923-1562
Practice Address - Street 1:132 S 10TH ST STE 3390
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:800-858-1662
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080219852085R0202X
NJ25MA102959002085R0202X
PAMD4427382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102624624Medicaid
NJ0270695Medicaid
PA102624624Medicaid