Healthcare Provider Details

I. General information

NPI: 1720055098
Provider Name (Legal Business Name): BORIS MEDAROV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 NEW SCOTLAND AVE # A-91
ALBANY NY
12208-3412
US

IV. Provider business mailing address

47 NEW SCOTLAND AVE # A-91
ALBANY NY
12208-3412
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5196
  • Fax:
Mailing address:
  • Phone: 518-262-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number042836
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number042836
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA105076
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA105076
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: