=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588918007
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KARAT LIBERTY MEDICAL CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2012
-----------------------------------------------------
Last Update Date | 04/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 OCEANA DR W APT 5F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-645-2900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 OCEANA DR W APT 5F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-645-2900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXANDRE KARATCHOUNOV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-645-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 238125
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------