Provider Demographics
NPI:1467739755
Name:PARK SOUTH PODIATRY LLC
Entity Type:Organization
Organization Name:PARK SOUTH PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ISRAEL
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:212-679-6776
Mailing Address - Street 1:450 PARK AVE S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-7320
Mailing Address - Country:US
Mailing Address - Phone:212-679-6776
Mailing Address - Fax:212-679-6538
Practice Address - Street 1:450 PARK AVE S
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-7320
Practice Address - Country:US
Practice Address - Phone:212-679-6776
Practice Address - Fax:212-679-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005362213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P95261Medicare PIN