MEDICARE: MARINA OSMOLOVSKY

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	246Z00000X	Other Specialist/Technologist	40826	NY
2	247100000X	Radiologic Technologist	40826	NY

General Provider Information

NPI Number	:	1922388735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA OSMOLOVSKY

Provider Business Mailing Address
First Line	:	111-29 QUEENS BLVD
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375
Country	:	US
Telephone Number	:	718-275-8900
Fax Number	:

Provider Business Practice Location Address
First Line	:	11129 QUEENS BLVD
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-5553
Country	:	US
Telephone Number	:	718-275-8900
Fax Number	:

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

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	08/24/2011

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