Provider Demographics
NPI:1912179110
Name:PARK AVENUE MEDICAL FAMILY PRACTICE & GERIATRICS, PC
Entity Type:Organization
Organization Name:PARK AVENUE MEDICAL FAMILY PRACTICE & GERIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:FELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:914-965-4300
Mailing Address - Street 1:102 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10703-2934
Mailing Address - Country:US
Mailing Address - Phone:914-965-4300
Mailing Address - Fax:914-965-7625
Practice Address - Street 1:102 PARK AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10703-2934
Practice Address - Country:US
Practice Address - Phone:914-965-4300
Practice Address - Fax:914-965-7625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148454261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01019209Medicaid
NY01019209Medicaid