=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568830834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR WELLNESS MEDICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 W 38TH ST RM 503
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-6368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-730-7232
-----------------------------------------------------
Fax | 212-687-0030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 W 38TH ST RM 503
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-6368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-730-7232
-----------------------------------------------------
Fax | 212-687-0030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | NINA MIRSAKOV
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 917-538-4132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------