Provider Demographics
NPI:1235162157
Name:MARYAMCHIK, ELENA (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MARYAMCHIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:KOLOVRAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:888 MAIN ST APT 236
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-0215
Mailing Address - Country:US
Mailing Address - Phone:305-699-1529
Mailing Address - Fax:
Practice Address - Street 1:327 E 64TH ST DEPT OF
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6704
Practice Address - Country:US
Practice Address - Phone:305-699-1529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279227207ZP0105X
NJ25MA11075400207ZP0105X
NY1347433207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304150600Medicaid