1174848501 NPI number — CENTRAL PARK PHYSICAL MEDICINE PC

Table of content: (NPI 1174848501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174848501 NPI number — CENTRAL PARK PHYSICAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL PARK PHYSICAL MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174848501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21714 MERRICK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAURELTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11413-1917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-270-8353
Provider Business Mailing Address Fax Number:
347-826-1917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21714 MERRICK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAURELTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11413-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-270-8353
Provider Business Practice Location Address Fax Number:
347-826-1917
Provider Enumeration Date:
03/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
THEAGENE
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
347-270-8353

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  194218-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 194218-1 . This is a "STATE OF NY EDUCATION DEPT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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