MEDICARE: MANANA PETROV PRIMARY MEDICAL CARE, 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	214204	NY

General Provider Information

NPI Number	:	1609948140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANANA PETROV PRIMARY MEDICAL CARE, PC

Provider Business Mailing Address
First Line	:	353 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-1308
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	353 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-1308
Country	:	US
Telephone Number	:	718-940-2100
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MANANA PETROV
Credential	:
Telephone Number	:	718-940-2100

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	06/21/2018

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