Healthcare Provider Details

I. General information

NPI: 1124274089
Provider Name (Legal Business Name): CHERRYL ANN PREMDASS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

2 VALENTINE DR
RENSSELAER NY
12144-9616
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax: 321-434-1775
Mailing address:
  • Phone: 860-545-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50454
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19557-875
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66149
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberAS2383278-0709
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number289112
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number37443
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME124797
License Number StateFL
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number289112
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: