Provider Demographics
NPI:1720055098
Name:MEDAROV, BORIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:MEDAROV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 NEW SCOTLAND AVE # A-91
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-5196
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVE # A-91
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042836207RC0200X, 207RP1001X
CAA105076207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356390009OtherGROUP NPI
CACE1617OtherGROUP RAILROAD MEDICARE
CAGR0100430OtherGROUP MEDICAL
CA1902846306OtherGROUP NPI
CAGROO16910OtherGROUP MEDICAID PIN
CAW11675OtherMEDICARE GROUP PIN
CAW18762OtherGROUP MEDICARE
CAW18762OtherGROUP MEDICARE
CTI29787Medicare UPIN
CAGR0100430OtherGROUP MEDICAL