Provider Demographics
NPI:1194860387
Name:RAPHAEL NOVOGRODSKY MD PC
Entity Type:Organization
Organization Name:RAPHAEL NOVOGRODSKY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVOGRODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-963-8112
Mailing Address - Street 1:401 RUTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-684-4482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181941 1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01497323Medicaid
NY37J841Medicare ID - Type Unspecified
NY01497323Medicaid
NJ519131Medicare ID - Type Unspecified