1053765388 NPI number — ARTEM YUSUPOV AUD

Table of content: ARTEM YUSUPOV AUD (NPI 1053765388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053765388 NPI number — ARTEM YUSUPOV AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YUSUPOV
Provider First Name:
ARTEM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
M

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:
1053765388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10825 72ND AVE
Provider Second Line Business Mailing Address:
STE 1A
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-7831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-561-9535
Provider Business Mailing Address Fax Number:
347-561-9513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10825 72ND AVE
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-7831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-480-8556
Provider Business Practice Location Address Fax Number:
347-561-9513
Provider Enumeration Date:
04/23/2016

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: 231H00000X , with the licence number:  00255881 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1134597701 . This is a "GROUP NPI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: A100146813 . This is a "SOLO MEDICARE PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 002588-1 . This is a "NYS AUDIOLOGY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: A400146814 . This is a "GROUP MEDICARE PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 04407801 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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