MEDICARE: STANISLAV KULISHOV PHYSICIAN P.C.

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	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	208948	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477627370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANISLAV KULISHOV PHYSICIAN P.C.

Provider Business Mailing Address
First Line	:	1833 E 13TH ST
Second Line	:	SUITE 1A
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2807
Country	:	US
Telephone Number	:	718-627-3939
Fax Number	:	718-627-8737

Provider Business Practice Location Address
First Line	:	1833 E 13TH ST
Second Line	:	SUITE 1A
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2807
Country	:	US
Telephone Number	:	718-627-3939
Fax Number	:	718-627-8737

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STANISLAV KULISHOV
Credential	:	MD
Telephone Number	:	718-627-3939

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	11/02/2012

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