Provider Demographics
NPI:1720070808
Name:MERECKI, EUGENE K (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:K
Last Name:MERECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-5051
Mailing Address - Country:US
Mailing Address - Phone:518-899-2632
Mailing Address - Fax:518-899-6418
Practice Address - Street 1:6 MEDICAL PARK DR
Practice Address - Street 2:SUITE 208
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-5051
Practice Address - Country:US
Practice Address - Phone:518-899-2632
Practice Address - Fax:518-899-6418
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2014-07-17
Deactivation Date:2006-04-10
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
NY180894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE42300Medicare PIN
NYAA1411Medicare ID - Type Unspecified
NYE42300Medicare UPIN