NPIMap

Organization Active NPI

Innovative Rehabilitation Consultant Medical PC

  • Pain Clinic/Center
  • Rego Park, NY
National Provider Identifier
1770880403
Registry record updated Jul 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Clinic/CenterTaxonomy code 261QP3300X
License
241269 Issued in NY
Legal business name
INNOVATIVE REHABILITATION CONSULTANT MEDICAL PC
Practice address
9701 66TH Ave
Rego Park, NY 11374-4245
Phone
(718) 275-5200
NPI assigned
Feb 15, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Dmitriy Fuzaylov, MDNPI 1093974040
Title
Ownder
Phone
(646) 784-3984

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Clinic/Center 261QP3300X 241269 NY Primary

Addresses

Primary practice location

9701 66TH Ave
Rego Park, NY 11374-4245

Mailing address

21429 Jamaica Ave
Queens Village, NY 11428-1733

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110926000421 NY Part B Supplier - Clinic/Group Practice 9739350695 Receives reassigned benefits from 7 practitioners
Practice locations: Rego Park, NY
O20210903002017 NY DME Supplier - Physician - General Practice 9739350695 Practice locations: Rego Park, NY

National Provider Directory

National Provider Directory

Locations

9701 66th Ave
Rego Park, NY 11374
Phone (718) 275-5200

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1297728000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1625788800000",
    "number": "1770880403",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21429 JAMAICA AVE",
            "city": "QUEENS VILLAGE",
            "state": "NY",
            "postal_code": "114281733"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9701 66TH AVE",
            "city": "REGO PARK",
            "state": "NY",
            "postal_code": "113744245",
            "telephone_number": "718-275-5200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNOVATIVE REHABILITATION CONSULTANT MEDICAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-15",
        "last_updated": "2021-07-09",
        "certification_date": "2021-07-09",
        "status": "A",
        "authorized_official_last_name": "FUZAYLOV",
        "authorized_official_first_name": "DMITRIY",
        "authorized_official_title_or_position": "OWNDER",
        "authorized_official_telephone_number": "646-784-3984",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP3300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Pain",
            "state": "NY",
            "license": "241269",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rego Park, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.