MEDICARE: MERMAID MEDICAL WELLNESS.PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	157270	NY

General Provider Information

NPI Number	:	1952545634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERMAID MEDICAL WELLNESS.PC

Provider Business Mailing Address
First Line	:	2885 WEST 15TH STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224
Country	:	US
Telephone Number	:	917-916-2371
Fax Number	:

Provider Business Practice Location Address
First Line	:	2885 WEST 15TH STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224
Country	:	US
Telephone Number	:	917-916-2371
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDOVARD J HAZEL
Credential	:	MD
Telephone Number	:	917-916-2371

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	04/27/2009

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