=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245296607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINA MIKOLAENKO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 09/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-263-2269
-----------------------------------------------------
Fax | 212-263-7916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3131 PRINCETON PIKE BLDG 5 SUITE 208
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-815-7829
-----------------------------------------------------
Fax | 609-815-7894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 40998
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 35088734
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZN0500X
-----------------------------------------------------
Taxonomy Name | Neuropathology Physician
-----------------------------------------------------
License Number | 248672
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------