Provider Demographics
NPI:1881656213
Name:PARKWAY MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:PARKWAY MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYNTRUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-613-1600
Mailing Address - Street 1:391 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4153
Mailing Address - Country:US
Mailing Address - Phone:718-613-1600
Mailing Address - Fax:718-613-1666
Practice Address - Street 1:391 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4153
Practice Address - Country:US
Practice Address - Phone:718-613-1600
Practice Address - Fax:718-613-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02109671Medicaid
NY000L51Medicare ID - Type Unspecified
NY02109671Medicaid
NYWEX931Medicare ID - Type Unspecified