Healthcare Provider Details

I. General information

NPI: 1942695275
Provider Name (Legal Business Name): PROSPECT AVE. MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3049 OCEAN PKWY FL 2
BROOKLYN NY
11235
US

IV. Provider business mailing address

PO BOX 230384
BROOKLYN NY
11223-0384
US

V. Phone/Fax

Practice location:
  • Phone: 718-704-9909
  • Fax: 347-702-5419
Mailing address:
  • Phone: 718-704-9909
  • Fax: 347-702-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number275763
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number275763
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number275763
License Number StateNY

VIII. Authorized Official

Name: YURA STOLYARSKY
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 718-704-9909