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General NPI Number Information
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NPI Number | 1083887913
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Entity Type | Organization
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Legal Business Name | B KONNIKOW PHYSICIAN PC
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Dates
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Enumeration Date | 04/11/2008
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Last Update Date | 04/14/2008
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Provider Practice Location Address
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Address Line | 11020 71ST RD #104
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City | FOREST HILLS
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State | NY
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Zip | 11375-4945
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Country | US
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Telephone | 718-263-3355
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Fax | 718-263-3373
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Provider Business Mailing Address
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Address Line | 7636 113TH ST 5B
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City | FOREST HILLS
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State | NY
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Zip | 11375-6513
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Country | US
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Telephone | 718-263-3355
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BORIS A KONNIKOW
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Credential | M.D.
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Telephone | 718-263-3355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 204106
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License Number State | NY
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