Provider Demographics
NPI:1881862472
Name:PARK AVENUE MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:PARK AVENUE MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FIROOZEH
Authorized Official - Middle Name:HOSSEINI
Authorized Official - Last Name:SHAHIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-533-3010
Mailing Address - Street 1:313 PARK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3327
Mailing Address - Country:US
Mailing Address - Phone:703-533-3010
Mailing Address - Fax:703-538-4316
Practice Address - Street 1:313 PARK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3327
Practice Address - Country:US
Practice Address - Phone:703-533-3010
Practice Address - Fax:703-538-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6006892Medicaid
VAE57384Medicare UPIN
DC085000Medicare PIN