MEDICARE: BORIS ISHAKOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1023648565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BORIS ISHAKOV

Provider Business Mailing Address
First Line	:	2705 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2705 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5004
Country	:	US
Telephone Number	:	646-374-7376
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	01/23/2020

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