Healthcare Provider Details

I. General information

NPI: 1407021231
Provider Name (Legal Business Name): ILYA KRAYEVSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E WALNUT ST
LONG BEACH NY
11561-3834
US

IV. Provider business mailing address

3 BOYLE RD
SELDEN NY
11784-4000
US

V. Phone/Fax

Practice location:
  • Phone: 516-521-8003
  • Fax:
Mailing address:
  • Phone: 631-736-4064
  • Fax: 631-736-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number264881
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: