1245467711 NPI number — STEVE B. PARK M.D. PC

Table of content: (NPI 1245467711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245467711 NPI number — STEVE B. PARK M.D. PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVE B. PARK M.D. 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:
6
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:
1245467711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 BUFFALO ROAD
Provider Second Line Business Mailing Address:
BLDG 700
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14624-1367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-328-0153
Provider Business Mailing Address Fax Number:
585-328-0158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 SAWGRASS DR
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14620-4648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-244-2200
Provider Business Practice Location Address Fax Number:
585-244-3416
Provider Enumeration Date:
06/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-328-0153

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , 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: 02364010 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11217A . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00468162 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01445376 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01728156 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00466308 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01093163 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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