Basic Information
| Provider Information | |||||||||
| NPI: | 1275604266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YELENA VAYNTRUB MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1231 78TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112282717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187577447 | ||||||||
| FaxNumber: | 7186131666 | ||||||||
| Practice Location | |||||||||
| Address1: | 391 EASTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112164153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186131600 | ||||||||
| FaxNumber: | 7186131666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | VAYNTRUB | ||||||||
| AuthorizedOfficialFirstName: | YELENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7187577447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 218887 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02109671 | 05 | NY | MEDICAID |