Provider Demographics
NPI:1700120946
Name:BERDICHEVSKY, RUSLAN (NP)
Entity Type:Individual
Prefix:MR
First Name:RUSLAN
Middle Name:
Last Name:BERDICHEVSKY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 VALLEY ST STE 6M103
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-2458
Mailing Address - Country:US
Mailing Address - Phone:401-566-8175
Mailing Address - Fax:
Practice Address - Street 1:166 VALLEY ST STE 6M103
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-2458
Practice Address - Country:US
Practice Address - Phone:401-566-8175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-10
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027653363L00000X, 363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics