Basic Information
| Provider Information | |||||||||
| NPI: | 1780726430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HRYNEWYCH | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 N WESTGATE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438455 | ||||||||
| FaxNumber: | 2172437951 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 N WESTGATE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438455 | ||||||||
| FaxNumber: | 2172437951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
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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 | 207V00000X | 036128851 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036128851 | 05 | IL | MEDICAID |