=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639509235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE MEDICAL CONCEPTS P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2013
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 E 46TH ST 7TH FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-390-1727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 OCEANA DR E APT. 3 C
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IGOR OSTROVSKY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-934-1920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 200155
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 200155
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------