Provider Demographics
NPI:1376879049
Name:PARK WEST MEDICAL ASSOCIATE PLLC
Entity Type:Organization
Organization Name:PARK WEST MEDICAL ASSOCIATE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OBUNIKE
Authorized Official - Middle Name:O
Authorized Official - Last Name:EDOKWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-940-2386
Mailing Address - Street 1:15 W 84TH ST
Mailing Address - Street 2:1J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4703
Mailing Address - Country:US
Mailing Address - Phone:212-362-3020
Mailing Address - Fax:212-362-3020
Practice Address - Street 1:15 W 84TH ST
Practice Address - Street 2:1J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4703
Practice Address - Country:US
Practice Address - Phone:212-362-3020
Practice Address - Fax:212-362-3020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180533261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center