1194739375 NPI number — DR. JOHN STANITSKI PARK M.D.

Table of content: (NPI 1801804091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194739375 NPI number — DR. JOHN STANITSKI PARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JOHN
Provider Middle Name:
STANITSKI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1194739375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 MEDICAL PKWY
Provider Second Line Business Mailing Address:
SUITE 235
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401-3046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-266-2770
Provider Business Mailing Address Fax Number:
410-841-6251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-266-2770
Provider Business Practice Location Address Fax Number:
410-841-6251
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  A95402 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: D0058193 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00471895 . This is a "PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: Q932 . This is a "AAD AA COUNTY" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: CN6292 . This is a "RR MEDICARE SHIPLEYS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: S629Q703 . This is a "MEDICARE ARA PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 10690030 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 021965A80 . This is a "AAD PG COUNTY" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 412620300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 545LQ923 . This is a "SHIPLEYS MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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