Basic Information
| Provider Information | |||||||||
| NPI: | 1972848307 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | A MERRYLAND OPERATING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | A MERRYLAND HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2873 W 17TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112242611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182650900 | ||||||||
| FaxNumber: | 7183602279 | ||||||||
| Practice Location | |||||||||
| Address1: | 2873 W 17TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112242611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182650900 | ||||||||
| FaxNumber: | 7183602279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | LESHCHINSKIY | ||||||||
| AuthorizedOfficialFirstName: | LIDIYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7182650900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | 097912 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7001134R | 01 | NY | OPERATING CERTIFICATE | OTHER |