Basic Information
| Provider Information | |||||||||
| NPI: | 1699854224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AKSENOV | ||||||||
| FirstName: | IGOR | ||||||||
| MiddleName: | VIKTOROVICH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WATERS AVE STE 507 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123504750 | ||||||||
| FaxNumber: | 9123504751 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE STE 507 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123504750 | ||||||||
| FaxNumber: | 9123504751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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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 | 207RP1001X | ME94813 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 062644 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 062644 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 062644 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | ME94813 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01286490 | 01 | AMERIGROUP | OTHER | 518768 | 01 | GA | WELLCARE | OTHER | 321479371B | 05 | GA | MEDICAID | 321479371A | 05 | GA | MEDICAID | P00733491 | 01 | GA | RAILROAD MEDICARE | OTHER | G62644 | 05 | SC | MEDICAID |