Provider Demographics
NPI:1952545634
Name:MERMAID MEDICAL WELLNESS.PC
Entity Type:Organization
Organization Name:MERMAID MEDICAL WELLNESS.PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDOVARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-916-2371
Mailing Address - Street 1:2885 WEST 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224
Mailing Address - Country:US
Mailing Address - Phone:917-916-2371
Mailing Address - Fax:
Practice Address - Street 1:2885 WEST 15TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224
Practice Address - Country:US
Practice Address - Phone:917-916-2371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty