MEDICARE: DMITRI PETRYCHENKO M.D.

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	227434	NY
2	208VP0014X	Interventional Pain Medicine Physician	25MA07665400	NJ
3	208VP0014X	Interventional Pain Medicine Physician	ME107824	FL
4	208VP0014X	Interventional Pain Medicine Physician	227434	NY

General Provider Information

NPI Number	:	1588644272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DMITRI PETRYCHENKO M.D.

Provider Business Mailing Address
First Line	:	2960 OCEAN AVE FL 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3202
Country	:	US
Telephone Number	:	718-336-5123
Fax Number	:	718-336-5137

Provider Business Practice Location Address
First Line	:	2960 OCEAN AVE FL 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3202
Country	:	US
Telephone Number	:	718-336-5123
Fax Number	:	718-336-5137

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	08/16/2023

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