Provider Demographics
NPI:1851763213
Name:PARK AVENUE PRIVATE PRACTICE LLC
Entity Type:Organization
Organization Name:PARK AVENUE PRIVATE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-433-5505
Mailing Address - Street 1:767 PARK AVE W STE 350
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2472
Mailing Address - Country:US
Mailing Address - Phone:847-433-5505
Mailing Address - Fax:
Practice Address - Street 1:767 PARK AVE W STE 350
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2472
Practice Address - Country:US
Practice Address - Phone:847-433-5505
Practice Address - Fax:847-433-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL248.001237261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service