Healthcare Provider Details

I. General information

NPI: 1972746196
Provider Name (Legal Business Name): MARINA RUBINOV PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11205 QUEENS BLVD
FOREST HILLS NY
11375-8311
US

IV. Provider business mailing address

112 05 QUEENS BLVD GROUND FLOOR FOREST HILLS
QUEENS NY
11375
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-1030
  • Fax: 718-886-4251
Mailing address:
  • Phone: 718-303-3725
  • Fax: 718-886-4215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number007627
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007627
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: