MEDICARE: MR. OLEG RYBALOV

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	174400000X	Specialist	612156121	NY
2	235Z00000X	Speech-Language Pathologist	022591	NY

General Provider Information

NPI Number	:	1174885867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OLEG RYBALOV

Provider Business Mailing Address
First Line	:	2388 OCEAN AVE
Second Line	:	APT. 7
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3564
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2388 OCEAN AVE
Second Line	:	APT. 7
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3564
Country	:	US
Telephone Number	:	191-741-7734
Fax Number	:

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

Provider Enumeration Date	:	06/09/2012
Last Update Date	:	02/23/2013

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Directions to “ MR. OLEG RYBALOV ” Practice Location

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