Basic Information
| Provider Information | |||||||||
| NPI: | 1609008119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IRINA MEDICAL P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2952 BRIGHTON 3RD ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112357078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189754334 | ||||||||
| FaxNumber: | 7189754337 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 OVINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112091550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182382625 | ||||||||
| FaxNumber: | 7182382704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOUKHARENKO | ||||||||
| AuthorizedOfficialFirstName: | IRINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7182382625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 232682 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02634619 | 05 | NY | MEDICAID |