Healthcare Provider Details

I. General information

NPI: 1154667749
Provider Name (Legal Business Name): IGOR RYVKIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 E 22ND ST
BROOKLYN NY
11210-5122
US

IV. Provider business mailing address

1485 E 22ND ST
BROOKLYN NY
11210-5122
US

V. Phone/Fax

Practice location:
  • Phone: 646-591-7394
  • Fax:
Mailing address:
  • Phone: 646-591-7394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number597970
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: