1952575417 NPI number — PARK AVENUE SPORTS MEDICINE & REHABILITATION PC

Table of content: (NPI 1952575417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952575417 NPI number — PARK AVENUE SPORTS MEDICINE & REHABILITATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK AVENUE SPORTS MEDICINE & REHABILITATION 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1952575417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11045 QUEENS BLVD 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-5519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-575-5050
Provider Business Mailing Address Fax Number:
718-575-8541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110-45 QUEENS BLVD
Provider Second Line Business Practice Location Address:
SUITE 117
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-575-5050
Provider Business Practice Location Address Fax Number:
718-575-8541
Provider Enumeration Date:
04/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WEG
Authorized Official First Name:
OSKAR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-575-5050

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  169749 , 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)





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