Provider Demographics
NPI:1821025362
Name:EDELMAN, MARTHA
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:EDELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7889
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:8900 VAN WYCK EXPRESSSWAY
Practice Address - Street 2:DEPT. OF PSYCHIATRY
Practice Address - City:RICHOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-206-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1795262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02219863Medicaid
NY0206EPMedicare ID - Type Unspecified
NY02219863Medicaid