Provider Demographics
NPI:1497721450
Name:POLOVENKO-KALLMAN, TATYANA N (MD)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:N
Last Name:POLOVENKO-KALLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:POLOVENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 409041
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9041
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002312207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02654593Medicaid
NY299AG1OtherBCBS
NYP00286376OtherRAILROAD
NY1099Q1Medicare PIN
NY299AG1OtherBCBS