Provider Demographics
NPI:1689886079
Name:MEYEROVICH MEDICAL & DIAGNOSTIC PC
Entity Type:Organization
Organization Name:MEYEROVICH MEDICAL & DIAGNOSTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:INESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYEROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-830-0400
Mailing Address - Street 1:9811 QUEENS BLVD
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3323
Mailing Address - Country:US
Mailing Address - Phone:718-830-0400
Mailing Address - Fax:718-830-0005
Practice Address - Street 1:9811 QUEENS BLVD
Practice Address - Street 2:SUITE 1E
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3323
Practice Address - Country:US
Practice Address - Phone:718-830-0400
Practice Address - Fax:718-830-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217870207R00000X
NY2187702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02228682Medicaid
NY02228682Medicaid