Provider Demographics
NPI:1023062163
Name:AW KULISCHENKO MD, I KULISCHENKO, MD
Entity type:Organization
Organization Name:AW KULISCHENKO MD, I KULISCHENKO, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROP./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:W
Authorized Official - Last Name:KULISCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-613-9155
Mailing Address - Street 1:495 RYDERS LN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2769
Mailing Address - Country:US
Mailing Address - Phone:732-613-9155
Mailing Address - Fax:732-651-0804
Practice Address - Street 1:495 RYDERS LN
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2769
Practice Address - Country:US
Practice Address - Phone:732-613-9155
Practice Address - Fax:732-651-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA43009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ527195Medicare PIN