Provider Demographics
NPI:1417058348
Name:PARK AVENUE MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:PARK AVENUE MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-685-5957
Mailing Address - Street 1:15 PARK AVE
Mailing Address - Street 2:MBX 16B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4348
Mailing Address - Country:US
Mailing Address - Phone:212-685-5957
Mailing Address - Fax:212-685-2822
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4348
Practice Address - Country:US
Practice Address - Phone:212-685-5957
Practice Address - Fax:212-685-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWXVPP1Medicare PIN