=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053359505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST MERRICK MEDICAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E MERRICK RD STE 306
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-872-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E MERRICK RD STE 306
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-872-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXANDER FALKOVSKY
-----------------------------------------------------
Credential | MD, DO
-----------------------------------------------------
Telephone | 516-872-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 206057
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------