Healthcare Provider Details

I. General information

NPI: 1811220882
Provider Name (Legal Business Name): LINDENWOOD MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 01/04/2022
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RALPH PL STE 112
STATEN ISLAND NY
10304-4408
US

IV. Provider business mailing address

11 RALPH PL STE 112
STATEN ISLAND NY
10304-4408
US

V. Phone/Fax

Practice location:
  • Phone: 718-954-2202
  • Fax:
Mailing address:
  • Phone: 718-954-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number251641
License Number StateNY

VIII. Authorized Official

Name: ZOYA KOROLEVA
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 718-954-2202