Basic Information
| Provider Information | |||||||||
| NPI: | 1487605788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANYLUK | ||||||||
| FirstName: | TARAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6896 W SNOWVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123503849 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 46678 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10064481 | 01 | GA | AMERIGROUP | OTHER | 121575904A | 05 | GA | MEDICAID | N194174 | 01 | GA | WELLCARE | OTHER | 884002 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | G46678 | 05 | SC | MEDICAID | 121575904A | 01 | GA | PEACHSTATE HEALTH PLAN | OTHER | BD6188242 | 01 | GA | DEA | OTHER |