Healthcare Provider Details

I. General information

NPI: 1841860442
Provider Name (Legal Business Name): PETRYCHENKO PAIN MANAGEMENT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E HALLANDALE BEACH BLVD STE 210
HALLANDALE BEACH FL
33009-3770
US

IV. Provider business mailing address

2100 E HALLANDALE BEACH BLVD STE 210
HALLANDALE BEACH FL
33009-3770
US

V. Phone/Fax

Practice location:
  • Phone: 212-951-1238
  • Fax: 718-336-5137
Mailing address:
  • Phone: 212-951-1238
  • Fax: 718-336-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DMITRI PETRYCHENKO
Title or Position: PRESIDENT
Credential: MD
Phone: 929-320-7481