Provider Demographics
NPI:1114140092
Name:PHYSICIANS PARK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PHYSICIANS PARK MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YAW
Authorized Official - Middle Name:O
Authorized Official - Last Name:ABU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-992-2316
Mailing Address - Street 1:12333 EQUINE LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3503
Mailing Address - Country:US
Mailing Address - Phone:561-992-2316
Mailing Address - Fax:561-993-3860
Practice Address - Street 1:124 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-3472
Practice Address - Country:US
Practice Address - Phone:561-992-2316
Practice Address - Fax:561-993-3860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71517207RP1001X
FLME73613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34222Medicare PIN