1891778064 NPI number — DR. BRIAN B PARK DC

Table of content: MATTHEW A WILLIAMS PT DPT (NPI 1528038239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891778064 NPI number — DR. BRIAN B PARK DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
BRIAN
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1891778064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9601 PULASKI PARK DR
Provider Second Line Business Mailing Address:
SUITE 416
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220-1409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-933-5678
Provider Business Mailing Address Fax Number:
410-933-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 EDMONDSON AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-947-0300
Provider Business Practice Location Address Fax Number:
410-947-0328
Provider Enumeration Date:
11/22/2005

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: 111N00000X , with the licence number:  S01759 , 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: 685841 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 794476 . This is a "CAQH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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