Active NPI
Alexandre Derevianko
- Surgical Assistant
- Great Lakes, IL
National Provider Identifier
1679987879
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Assistant
- License
- 238000408
- Practice address
- 1811 Arkansas Ave
Great Lakes, IL 60088-4244 - Phone
- (401) 480-9807
- Fax
- (847) 733-5827
- NPI assigned
- Jun 16, 2014
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgical Assistant | 246ZC0007X | 238000408 | IL | Primary |
Addresses
Primary practice location
1811 Arkansas Ave
Great Lakes, IL 60088-4244
Mailing address
1811 Arkansas Ave
Great Lakes, IL 60088-4244
Phone (401) 480-9807
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 238000408 | Other | IL | LICENSE NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 238000408 | IL | MD | Surgical Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1402876800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1403136000000",
"number": "1679987879",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1811 ARKANSAS AVE",
"city": "GREAT LAKES",
"state": "IL",
"postal_code": "600884244",
"telephone_number": "401-480-9807",
"fax_number": "847-733-5827"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1811 ARKANSAS AVE",
"city": "GREAT LAKES",
"state": "IL",
"postal_code": "600884244",
"telephone_number": "401-480-9807",
"fax_number": "847-733-5827"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DEREVIANKO",
"first_name": "ALEXANDRE",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2014-06-16",
"last_updated": "2014-06-19",
"status": "A"
},
"taxonomies": [
{
"code": "246ZC0007X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Other, Surgical Assistant",
"state": "IL",
"license": "238000408",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE NUMBER",
"identifier": "238000408",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Great Lakes, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.