Basic Information
| Provider Information | |||||||||
| NPI: | 1639165459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEXANDER INFUSION LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVANTI HEALTH CARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329961187 | ||||||||
| FaxNumber: | 2152821587 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 NASSAU TERMINAL RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110404927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162801000 | ||||||||
| FaxNumber: | 5162801075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAACH | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8568231574 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 023601 | NY | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03009794 | 05 | NY | MEDICAID |