Provider Demographics
NPI:1376860007
Name:SERGEY A KALITENKO PHYSICIAN P C
Entity Type:Organization
Organization Name:SERGEY A KALITENKO PHYSICIAN P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KALITENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-382-9200
Mailing Address - Street 1:PO BOX 297248
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-7248
Mailing Address - Country:US
Mailing Address - Phone:718-382-9200
Mailing Address - Fax:718-382-9201
Practice Address - Street 1:2158 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1421
Practice Address - Country:US
Practice Address - Phone:718-382-9200
Practice Address - Fax:718-382-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1884413Medicaid
NY1884413Medicaid