Provider Demographics
NPI:1073914206
Name:PARK WEST HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:PARK WEST HEALTH SYSTEM, INC.
Other - Org Name:HOWARD PARK COMMUNITY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-542-7800
Mailing Address - Street 1:4601 LIBERTY HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-7553
Mailing Address - Country:US
Mailing Address - Phone:410-542-7800
Mailing Address - Fax:410-542-3014
Practice Address - Street 1:4601 LIBERTY HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-7553
Practice Address - Country:US
Practice Address - Phone:443-884-7577
Practice Address - Fax:667-239-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD912391100Medicaid