Provider Demographics
NPI:1942695275
Name:PROSPECT AVE. MEDICAL P.C.
Entity Type:Organization
Organization Name:PROSPECT AVE. MEDICAL P.C.
Other - Org Name:PROSPECT MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YURA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLYARSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-704-9909
Mailing Address - Street 1:PO BOX 230384
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-0384
Mailing Address - Country:US
Mailing Address - Phone:718-704-9909
Mailing Address - Fax:347-702-5419
Practice Address - Street 1:3049 OCEAN PKWY FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-704-9909
Practice Address - Fax:347-702-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2757632081P2900X, 261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty