MEDICARE: PETRYCHENKO PHYSICIAN 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	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WEL581	OTHER	NY	MEDICARE

General Provider Information

NPI Number	:	1861413981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETRYCHENKO PHYSICIAN PC

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	:	PRESIDENT
Name	:	DR. DMITRI PETRYCHENKO
Credential	:	M.D.
Telephone Number	:	718-336-5123

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	12/26/2014

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