MEDICARE: INNA PETROSOVA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	216610	NY

General Provider Information

NPI Number	:	1609861004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INNA PETROSOVA MD

Provider Business Mailing Address
First Line	:	2233 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3029
Country	:	US
Telephone Number	:	718-258-3777
Fax Number	:	718-258-6284

Provider Business Practice Location Address
First Line	:	2233 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3029
Country	:	US
Telephone Number	:	718-258-3777
Fax Number	:	718-258-6284

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	04/02/2010

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