Basic Information
| Provider Information | |||||||||
| NPI: | 1508017062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANANA PETROV PRIMARY MEDICAL CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 OCEAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112261308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189402100 | ||||||||
| FaxNumber: | 7189402100 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 OCEAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112261308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | PETROV | ||||||||
| AuthorizedOfficialFirstName: | MANANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7188506345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.