Provider Demographics
NPI:1205101862
Name:ALEXANDER PUSHKA MD PA
Entity type:Organization
Organization Name:ALEXANDER PUSHKA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSHKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-579-1110
Mailing Address - Street 1:7369 SHERIDAN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2776
Mailing Address - Country:US
Mailing Address - Phone:954-983-5330
Mailing Address - Fax:954-983-5086
Practice Address - Street 1:7369 SHERIDAN ST STE 203
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2776
Practice Address - Country:US
Practice Address - Phone:954-983-5330
Practice Address - Fax:954-983-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME886662084P0800X, 2084P0804X
363A00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004704500OtherGROUP MEDICAID NUMBER
FL004704500OtherGROUP MEDICAID NUMBER
FLU3780OtherMEDICARE PTAN
FLGB841AOtherMEDICARE GROUP PTAN
FLU3780XOtherMEDICARE PTAN
FLGB841AOtherMEDICARE GROUP PTAN