=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225218175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSCOW MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 04/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 70TH ST SUITE# 3A
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11228-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-992-0912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 70TH ST SUITE# 3A
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11228-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-992-0912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | IRINE CORST
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 917-992-0912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 214541
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------