MEDICARE: MERMAID MANAGEMENT INC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1962793273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERMAID MANAGEMENT INC

Provider Business Mailing Address
First Line	:	170406 MERMAID AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-2622
Country	:	US
Telephone Number	:	718-265-0900
Fax Number	:	718-265-6319

Provider Business Practice Location Address
First Line	:	1704 06 MERMAID AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-2622
Country	:	US
Telephone Number	:	718-265-0900
Fax Number	:	718-265-6319

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ARMEN GAMBARIAN
Credential	:
Telephone Number	:	718-265-0900

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	04/21/2011

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