Provider Demographics
NPI:1013568435
Name:PARK AVENUE MEDICAL OFFICE, PLLC
Entity Type:Organization
Organization Name:PARK AVENUE MEDICAL OFFICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WELLINGTON
Authorized Official - Middle Name:S
Authorized Official - Last Name:TICHENOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-517-6611
Mailing Address - Street 1:642 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6105
Mailing Address - Country:US
Mailing Address - Phone:212-517-6611
Mailing Address - Fax:212-517-2132
Practice Address - Street 1:642 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6105
Practice Address - Country:US
Practice Address - Phone:212-517-6611
Practice Address - Fax:212-517-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Single Specialty