Provider Demographics
NPI:1619144904
Name:HADASSAH OBGYN PLLC
Entity Type:Organization
Organization Name:HADASSAH OBGYN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-725-0123
Mailing Address - Street 1:PO BOX 231023
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-0023
Mailing Address - Country:US
Mailing Address - Phone:212-725-0123
Mailing Address - Fax:212-725-3738
Practice Address - Street 1:22 E 36TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3419
Practice Address - Country:US
Practice Address - Phone:212-725-0123
Practice Address - Fax:212-725-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163782305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization