Provider Demographics
NPI:1306816285
Name:BOSTON ROAD MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:BOSTON ROAD MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF THE MEDICAL PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:VALERI
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-863-8663
Mailing Address - Street 1:31 AMANDA LN
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-3313
Mailing Address - Country:US
Mailing Address - Phone:718-863-8621
Mailing Address - Fax:718-863-8261
Practice Address - Street 1:2190 BOSTON RD
Practice Address - Street 2:SUITE 1N
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1201
Practice Address - Country:US
Practice Address - Phone:718-863-8663
Practice Address - Fax:718-863-8261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023196Medicaid
NY023196Medicaid