Provider Demographics
NPI:1629004114
Name:PARK MEDICAL CENTER
Entity Type:Organization
Organization Name:PARK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-264-4541
Mailing Address - Street 1:847 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4117
Mailing Address - Country:US
Mailing Address - Phone:904-264-4541
Mailing Address - Fax:904-278-2709
Practice Address - Street 1:847 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4117
Practice Address - Country:US
Practice Address - Phone:904-264-4541
Practice Address - Fax:904-278-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0012468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487621736OtherNPI
1013985035OtherNPI
1053388306OtherNPI
1013985035OtherNPI