Provider Demographics
NPI:1689656654
Name:EIDELMAN, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EIDELMAN
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 1:245 W 19TH ST
Mailing Address - Street 2:GROUND FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4072
Mailing Address - Country:US
Mailing Address - Phone:212-675-0549
Mailing Address - Fax:212-675-0540
Practice Address - Street 1:245 W 19TH ST
Practice Address - Street 2:GROUND FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4072
Practice Address - Country:US
Practice Address - Phone:212-675-0549
Practice Address - Fax:212-675-0540
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209980207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01998356Medicaid
G62378Medicare UPIN
NY01998356Medicaid