Healthcare Provider Details

I. General information

NPI: 1801863659
Provider Name (Legal Business Name): BORIS MARKOVICH PETRIKOVSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE MEDICAL STAFF OFFICE BOX 42
EAST MEADOW NY
11554
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-6255
  • Fax: 516-572-3124
Mailing address:
  • Phone: 516-572-6255
  • Fax: 516-572-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number163782
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number163782-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: