Provider Demographics
NPI:1669537882
Name:HERCULES MEDICAL PC
Entity type:Organization
Organization Name:HERCULES MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMAEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-348-5100
Mailing Address - Street 1:177 EAST 87TH ST
Mailing Address - Street 2:STE 406
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2226
Mailing Address - Country:US
Mailing Address - Phone:212-348-5100
Mailing Address - Fax:212-410-3507
Practice Address - Street 1:177 EAST 87TH ST
Practice Address - Street 2:STE 406
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2226
Practice Address - Country:US
Practice Address - Phone:212-348-5100
Practice Address - Fax:212-410-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWAW051Medicare ID - Type UnspecifiedGROUP