Active NPI
Boris Mirochnik
- Psychologist
- Staten Island, NY
National Provider Identifier
1639254337
On this page
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128b(4) exclusion effective Jan 20, 2015.
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- R065562
- Practice address
- 48 Blueberry Lane
Staten Island, NY 10312 - Phone
- (718) 967-1585
- Fax
- (718) 967-1585
- NPI assigned
- Oct 25, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | R065562 | NY | Primary |
Addresses
Primary practice location
48 Blueberry Lane
Staten Island, NY 10312
Mailing address
48 Blueberry Lane
Staten Island, NY 10312
Phone (718) 967-1585
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02335308 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R065562 | NY | MD | Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Little Penguin | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Group Psychotherapy Psychologist
- Staten Island, NY
- NPI 1720268451
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161734400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1198713600000",
"number": "1639254337",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "48 BLUEBERRY LANE",
"city": "STATEN ISLAND",
"state": "NY",
"postal_code": "10312",
"telephone_number": "718-967-1585",
"fax_number": "718-967-1585"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "48 BLUEBERRY LANE",
"city": "STATEN ISLAND",
"state": "NY",
"postal_code": "10312",
"telephone_number": "718-967-1585",
"fax_number": "718-967-1585"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MIROCHNIK",
"first_name": "BORIS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-25",
"last_updated": "2007-12-27",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "NY",
"license": "R065562",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "02335308",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Staten Island, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.