Healthcare Provider Details

I. General information

NPI: 1902882038
Provider Name (Legal Business Name): MICHAEL TYSHKOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

584 FOREST AVE
STATEN ISLAND NY
10310-2512
US

IV. Provider business mailing address

1 EDGEWATER ST 6TH FL. PAYER RELATIONS
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-5619
  • Fax: 718-226-5620
Mailing address:
  • Phone: 718-226-1008
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number180877
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: