Healthcare Provider Details

I. General information

NPI: 1053156638
Provider Name (Legal Business Name): ELIZABETH RADOVICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 SHEEPSHEAD BAY RD
BROOKLYN NY
11224-3621
US

IV. Provider business mailing address

7110 BENNETT CT
BROOKLYN NY
11209-1404
US

V. Phone/Fax

Practice location:
  • Phone: 718-946-2600
  • Fax:
Mailing address:
  • Phone: 646-207-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number720328
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: