=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245916014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAPHAEL NOVOGRODSKY MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 WATERS PL SUITE 1207
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-684-4482
-----------------------------------------------------
Fax | 718-918-9778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 RUTLAND AVE
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-684-4482
-----------------------------------------------------
Fax | 718-918-9778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAPHAEL NOVOGRODSKY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 201-638-3640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------