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General NPI Number Information
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NPI Number | 1467968834
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Entity Type | Organization
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Legal Business Name | KOLESNIKOV PEDIATRICS PLLC
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Dates
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Enumeration Date | 12/21/2017
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Last Update Date | 12/21/2017
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Provider Practice Location Address
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Address Line | 120 PONDEROSA DR
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City | JENKINS
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State | KY
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Zip | 41537
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Country | US
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Telephone | 980-565-9500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 60623
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City | STATEN ISLAND
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State | NY
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Zip | 10306-0623
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANDREY KOLESNIKOV
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Credential |
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Telephone | 980-565-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 287701
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License Number State | NY
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