Provider Demographics
NPI:1699726315
Name:ADVANCED WOUND CARE MEDICAL PC
Entity type:Organization
Organization Name:ADVANCED WOUND CARE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCHLATYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-382-3400
Mailing Address - Street 1:454 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4011
Mailing Address - Country:US
Mailing Address - Phone:718-382-3400
Mailing Address - Fax:718-382-3420
Practice Address - Street 1:454 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4011
Practice Address - Country:US
Practice Address - Phone:718-382-3400
Practice Address - Fax:718-382-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218265207R00000X
NY150869208600000X
NY087860208600000X
NY227059208D00000X
NY156598208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07132OtherGHI MEDICARE
NYWEQ861Medicare PIN