Healthcare Provider Details

I. General information

NPI: 1053379362
Provider Name (Legal Business Name): MERMAID OPERATING CO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 MERMAID AVE
BROOKLYN NY
11224-2622
US

IV. Provider business mailing address

1704 MERMAID AVE
BROOKLYN NY
11224-2622
US

V. Phone/Fax

Practice location:
  • Phone: 718-265-0900
  • Fax: 718-265-6319
Mailing address:
  • Phone: 718-265-0900
  • Fax: 718-265-6319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS PEREZ
Title or Position: DIRECTOR
Credential: MD
Phone: 718-265-0900