Provider Demographics
NPI:1801037007
Name:PARK AVENUE MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:PARK AVENUE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-949-1199
Mailing Address - Street 1:3 BARKER AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-1509
Mailing Address - Country:US
Mailing Address - Phone:914-949-1199
Mailing Address - Fax:914-949-1245
Practice Address - Street 1:3 BARKER AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1509
Practice Address - Country:US
Practice Address - Phone:914-949-1199
Practice Address - Fax:914-949-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty