Basic Information
Provider Information | |||||||||
NPI: | 1497742795 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIYUFY | ||||||||
FirstName: | ALEX | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O.BOX 5982 | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234710982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572285201 | ||||||||
FaxNumber: | 7574816175 | ||||||||
Practice Location | |||||||||
Address1: | 762 INDEPENDENCE BLVD STE 772 | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234556200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572285201 | ||||||||
FaxNumber: | 7574816175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2005 | ||||||||
LastUpdateDate: | 03/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305203959 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2255A2300X | 0126000740 | VA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
ID | Type | State | Issuer | Description | 010339201 | 05 | VA |   | MEDICAID | 010339219 | 05 | VA |   | MEDICAID | 010337909 | 05 | VA |   | MEDICAID | 010337917 | 05 | VA |   | MEDICAID | 010338239 | 05 | VA |   | MEDICAID | 010339227 | 05 | VA |   | MEDICAID |