MEDICARE: MR. DMITRY MERENER MS. ED

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	174400000X	Specialist	1252369	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EDU-106541001	OTHER	NY	LIBERTY INSURANCE UNDERWRITERS INC.

General Provider Information

NPI Number	:	1902152101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DMITRY MERENER MS. ED

Provider Business Mailing Address
First Line	:	3395 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4055
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 BRIGHTON BEACH AVE APT 6B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5838
Country	:	US
Telephone Number	:	646-404-4444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/25/2012

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