Provider Demographics
NPI:1326308719
Name:PARK AVE MEDICAL GROUP
Entity Type:Organization
Organization Name:PARK AVE MEDICAL GROUP
Other - Org Name:PARK AVE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOSS
Authorized Official - Prefix:DR
Authorized Official - First Name:ADLAI
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-886-0611
Mailing Address - Street 1:424 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4152
Mailing Address - Country:US
Mailing Address - Phone:407-886-0611
Mailing Address - Fax:407-886-2817
Practice Address - Street 1:424 N PARK AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-4152
Practice Address - Country:US
Practice Address - Phone:407-886-0611
Practice Address - Fax:407-886-2817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOPKA WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21409Medicare UPIN