Provider Demographics
NPI:1821246869
Name:THE PARK CLINIC FOR COSMETIC AND RECONSTRUCTIVE SURGERY, P.C.
Entity Type:Organization
Organization Name:THE PARK CLINIC FOR COSMETIC AND RECONSTRUCTIVE SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-340-6600
Mailing Address - Street 1:PO BOX 852047
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-2047
Mailing Address - Country:US
Mailing Address - Phone:251-340-6600
Mailing Address - Fax:
Practice Address - Street 1:3153 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4061
Practice Address - Country:US
Practice Address - Phone:251-340-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOBILE PLASTIC AND RECONSTRUCTIVE SURGERY AND DERMATOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-03
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.28938261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510G700432OtherMEDICARE PTAN
AL510G700432OtherRAILROAD MEDICARE PTAN
AL51595045OtherBLUE CROSS BLUE SHIELD AL