Provider Demographics
NPI:1790873602
Name:BEYDER, ILYA
Entity Type:Individual
Prefix:MR
First Name:ILYA
Middle Name:
Last Name:BEYDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8023 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4507
Mailing Address - Country:US
Mailing Address - Phone:414-302-6337
Mailing Address - Fax:414-755-2039
Practice Address - Street 1:8023 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4507
Practice Address - Country:US
Practice Address - Phone:414-302-6337
Practice Address - Fax:414-755-2039
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI87-078373OtherMEDICAL SUPPY