Basic Information
| Provider Information | |||||||||
| NPI: | 1376071001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEVTSOV | ||||||||
| FirstName: | ALEKSANDR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 432 | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415020432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107358783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2017 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 04931 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2018-01812 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.