MEDICARE: DR. ILYA DOMNICH M.D.

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	217873	NY

General Provider Information

NPI Number	:	1699793034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILYA DOMNICH M.D.

Provider Business Mailing Address
First Line	:	1687 RALPH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3319
Country	:	US
Telephone Number	:	718-251-7191
Fax Number	:	718-209-1891

Provider Business Practice Location Address
First Line	:	1687 RALPH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3319
Country	:	US
Telephone Number	:	718-251-7191
Fax Number	:	718-209-1891

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/24/2007

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