Provider Demographics
NPI:1245275320
Name:KIANOVSKI, SERGE (DPT)
Entity type:Individual
Prefix:
First Name:SERGE
Middle Name:
Last Name:KIANOVSKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:SERGEY
Other - Middle Name:
Other - Last Name:KIYANOVSKIY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:7803 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1207
Mailing Address - Country:US
Mailing Address - Phone:718-232-7778
Mailing Address - Fax:718-232-9634
Practice Address - Street 1:7803 20TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1207
Practice Address - Country:US
Practice Address - Phone:718-232-7778
Practice Address - Fax:718-232-9634
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016388225100000X, 2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016388OtherHIP
NY02012040Medicaid
NYP2459083OtherOXFORD
NY3C6820OtherHEALTH NET
NY833574OtherEMPIRE PLAN (MPN)
NY11081573OtherMULTIPLAN
NY6698961OtherGHI
NYBK0224704OtherAMERICHOICE
NYQC2011OtherEMPIRE BCBS
NY136981OtherCHN
NY177236OtherELDER PLAN
NY02012040Medicaid
NYBK0224704OtherAMERICHOICE