MEDICARE: MR. BORIS I PALTIELOV P.T.

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	225100000X	Physical Therapist	020951	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G400001326	OTHER	NY	PTAN

General Provider Information

NPI Number	:	1134155492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BORIS I PALTIELOV P.T.

Provider Business Mailing Address
First Line	:	11027 70TH RD
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3933
Country	:	US
Telephone Number	:	718-606-1911
Fax Number	:	718-709-4166

Provider Business Practice Location Address
First Line	:	6405 YELLOWSTONE BLVD APT 101
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1534
Country	:	US
Telephone Number	:	718-606-1911
Fax Number	:	718-709-4166

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

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	10/24/2023

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