1255367405 NPI number — MRS. SVETLANA KIBRIK PT

Table of content: MRS. SVETLANA KIBRIK PT (NPI 1255367405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255367405 NPI number — MRS. SVETLANA KIBRIK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIBRIK
Provider First Name:
SVETLANA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255367405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1543 WEST 1ST STREET
Provider Second Line Business Mailing Address:
APT F1
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-769-9986
Provider Business Mailing Address Fax Number:
347-254-6083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1543 WEST 1ST STREET
Provider Second Line Business Practice Location Address:
APT F1
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-769-9986
Provider Business Practice Location Address Fax Number:
347-254-6083
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  021229 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: QA0116300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02284655 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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