Basic Information
| Provider Information | |||||||||
| NPI: | 1568830834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR WELLNESS MEDICAL SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 474 OVINGTON AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112091550 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 474 OVINGTON AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112091550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182382625 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | MIRSAKOV | ||||||||
| AuthorizedOfficialFirstName: | NINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7182382625 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 244792 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.