Provider Demographics
NPI:1740546399
Name:PARK AVENUE MEDICAL
Entity type:Organization
Organization Name:PARK AVENUE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANACE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-309-0070
Mailing Address - Street 1:85 BARNES RD STE 202
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-309-0070
Mailing Address - Fax:203-309-0071
Practice Address - Street 1:85 BARNES RD STE 202
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-309-0070
Practice Address - Fax:203-309-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002162Medicaid
CTI43983Medicare UPIN