Provider Demographics
NPI:1518013283
Name:PARK WEST HEALTH SYSTEMS, INCORPORATED
Entity Type:Organization
Organization Name:PARK WEST HEALTH SYSTEMS, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-542-7800
Mailing Address - Street 1:3319 W BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5103
Mailing Address - Country:US
Mailing Address - Phone:410-542-7800
Mailing Address - Fax:410-542-5279
Practice Address - Street 1:5101 LANIER AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5321
Practice Address - Country:US
Practice Address - Phone:410-542-7800
Practice Address - Fax:410-542-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD912391100Medicaid
MD211827Medicare Oscar/Certification