Provider Demographics
NPI:1710934765
Name:BARANOV, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BARANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15611 AGUILAR AVE # 1018
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2732
Mailing Address - Country:US
Mailing Address - Phone:718-975-3515
Mailing Address - Fax:718-975-3514
Practice Address - Street 1:4119 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5709
Practice Address - Country:US
Practice Address - Phone:718-975-3515
Practice Address - Fax:718-975-3514
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP11402Medicare UPIN
NYQB7051Medicare ID - Type Unspecified