MEDICARE: MR. BORIS POLONSKIY DPT

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	PT38484	FL
2	225100000X	Physical Therapist	40QA01591600	NJ
3	225100000X	Physical Therapist	028006	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	:	1710910112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BORIS POLONSKIY DPT

Provider Business Mailing Address
First Line	:	1835 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2560
Country	:	US
Telephone Number	:	718-502-5271
Fax Number	:	718-701-1188

Provider Business Practice Location Address
First Line	:	1835 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2560
Country	:	US
Telephone Number	:	718-502-5271
Fax Number	:	718-701-1188

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	08/29/2023

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