MEDICARE: IZRAEL POLVANOV RN

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	163W00000X	Registered Nurse	770613	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831824523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IZRAEL POLVANOV RN

Provider Business Mailing Address
First Line	:	6837 YELLOWSTONE BLVD APT D42
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3413
Country	:	US
Telephone Number	:	718-541-0852
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 VERNON BLVD
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11106-5121
Country	:	US
Telephone Number	:	877-889-0836
Fax Number	:

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

Provider Enumeration Date	:	07/18/2022
Last Update Date	:	07/18/2022

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