Provider Demographics
NPI:1639101462
Name:PARK HEIGHTS MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PARK HEIGHTS MEDICAL CLINIC LLC
Other - Org Name:JAI MEDICAL CENTER/ PARK HEIGHTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAI
Authorized Official - Middle Name:M
Authorized Official - Last Name:SEUNARINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-433-2200
Mailing Address - Street 1:5010 YORK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-4437
Mailing Address - Country:US
Mailing Address - Phone:410-433-2200
Mailing Address - Fax:410-532-7246
Practice Address - Street 1:4340 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6725
Practice Address - Country:US
Practice Address - Phone:410-542-8130
Practice Address - Fax:410-542-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO14391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK614PAOtherBLUECROSS/BLUESHEILD MD
MD069231000Medicaid
MD1347OtherJAI MEDICAL SYSTEM MCO