Provider Demographics
NPI:1679775159
Name:MORERO-MARDACH MEDICAL GROUP PC
Entity Type:Organization
Organization Name:MORERO-MARDACH MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MORERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-366-1583
Mailing Address - Street 1:149 ST.NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237
Mailing Address - Country:US
Mailing Address - Phone:718-366-1583
Mailing Address - Fax:718-386-0080
Practice Address - Street 1:149 ST.NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237
Practice Address - Country:US
Practice Address - Phone:718-366-1583
Practice Address - Fax:718-386-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05775Medicare PIN
NYWER211Medicare PIN