Provider Demographics
NPI:1467850461
Name:PARKSIDE MEDICAL, LLC
Entity Type:Organization
Organization Name:PARKSIDE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-539-0055
Mailing Address - Street 1:501 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2956
Mailing Address - Country:US
Mailing Address - Phone:928-782-9000
Mailing Address - Fax:
Practice Address - Street 1:501 W 8TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2956
Practice Address - Country:US
Practice Address - Phone:928-782-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty