Basic Information
| Provider Information | |||||||||
| NPI: | 1124063219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISIMOVA | ||||||||
| FirstName: | MERI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8900 VAN WYCK EXPY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067160 | ||||||||
| FaxNumber: | 7182067169 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPY | ||||||||
| Address2: | DEPT. OF PSYCHIATRY | ||||||||
| City: | RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067160 | ||||||||
| FaxNumber: | 7182067169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 235257 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 02673201 | 05 | NY | MEDICAID |