Provider Demographics
NPI:1174848501
Name:CENTRAL PARK PHYSICAL MEDICINE PC
Entity Type:Organization
Organization Name:CENTRAL PARK PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THEAGENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-270-8353
Mailing Address - Street 1:21714 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1917
Mailing Address - Country:US
Mailing Address - Phone:347-270-8353
Mailing Address - Fax:347-826-1917
Practice Address - Street 1:21714 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1917
Practice Address - Country:US
Practice Address - Phone:347-270-8353
Practice Address - Fax:347-826-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194218-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY194218-1OtherSTATE OF NY EDUCATION DEPT