Provider Demographics
NPI:1245916014
Name:RAPHAEL NOVOGRODSKY MD PC
Entity type:Organization
Organization Name:RAPHAEL NOVOGRODSKY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVOGRODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-638-3640
Mailing Address - Street 1:401 RUTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666
Mailing Address - Country:US
Mailing Address - Phone:718-684-4482
Mailing Address - Fax:718-918-9778
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:SUITE 1207
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-684-4482
Practice Address - Fax:718-918-9778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01497323Medicaid