MEDICARE: INNA PETROSOVA MEDICAL PC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1063629525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNA PETROSOVA MEDICAL PC

Provider Business Mailing Address
First Line	:	2233 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3029
Country	:	US
Telephone Number	:	718-258-3777
Fax Number	:	718-258-6284

Provider Business Practice Location Address
First Line	:	2233 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3029
Country	:	US
Telephone Number	:	718-258-3777
Fax Number	:	718-258-6284

Authorized Official
Title or Position	:	OWNER
Name	:	INNA PETROSOVA
Credential	:	MD
Telephone Number	:	718-258-3777

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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