Basic Information
| Provider Information | |||||||||
| NPI: | 1669451225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRAVCHENKO | ||||||||
| FirstName: | IGOR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 7878 N 16TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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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 | 207L00000X | 37002 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 340664 | 05 | AZ | MEDICAID |