Provider Demographics
NPI:1790725315
Name:KORKHOV, VADIM EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:VADIM
Middle Name:EDWARD
Last Name:KORKHOV
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 1:1411 GRANDVIEW AVE
Mailing Address - Street 2:#103
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15211-1165
Mailing Address - Country:US
Mailing Address - Phone:917-476-2065
Mailing Address - Fax:
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231475207RC0200X
MDD0068240207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000554504OtherANTHEM
IN200890270Medicaid
MDKS04Medicare PIN
IN200890270Medicaid
IN070860YYYYMedicare PIN