=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306026596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXEY MIGIROV MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2007
-----------------------------------------------------
Last Update Date | 11/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 CORBIN AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10308-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-372-9300
-----------------------------------------------------
Fax | 718-837-0460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7508 BAY PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11214-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-372-9300
-----------------------------------------------------
Fax | 718-837-0460
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | MR. ALEXEY MIGIROV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-372-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 223268-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------