Basic Information
| Provider Information | |||||||||
| NPI: | 1548236417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOLYAR | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 409041 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303849041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3045232241 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 55TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112202559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 227967-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 227967-1 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1396Q1 | 01 | NY | BLUECROSS BLUESHIELD | OTHER | 02407298 | 05 | NY | MEDICAID | P00334127 | 01 | RAILROAD | OTHER |