Provider Demographics
NPI:1255775227
Name:MERRIDERM DERMATOLOGY PLLC
Entity type:Organization
Organization Name:MERRIDERM DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-732-0690
Mailing Address - Street 1:3644 MAIN ST # 2NDFL
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4105
Mailing Address - Country:US
Mailing Address - Phone:347-732-0690
Mailing Address - Fax:347-732-0691
Practice Address - Street 1:3644 MAIN ST # 2NDFL
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4105
Practice Address - Country:US
Practice Address - Phone:347-732-0690
Practice Address - Fax:347-732-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266027261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03509437Medicaid
NY03509437Medicaid