Basic Information
Provider Information | |||||||||
NPI: | 1518540517 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | SERENA | ||||||||
MiddleName: | MIKHAL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FREIMAN | ||||||||
OtherFirstName: | MIKHAL | ||||||||
OtherMiddleName: | SERENA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1415 N POINTE CT | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477258313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8582204614 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1501 N CAMPBELL AVE STE 8401 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857240001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206269245 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2021 | ||||||||
LastUpdateDate: | 04/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | R78678 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.