Provider Demographics
NPI:1205094562
Name:PARK AVE AMBULATORY MEDICAL FACILITY
Entity type:Organization
Organization Name:PARK AVE AMBULATORY MEDICAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHNERIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-422-5023
Mailing Address - Street 1:360 COURT ST
Mailing Address - Street 2:SUITE# 3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-4353
Mailing Address - Country:US
Mailing Address - Phone:718-422-5023
Mailing Address - Fax:718-422-5025
Practice Address - Street 1:360 COURT ST
Practice Address - Street 2:SUITE# 3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-4353
Practice Address - Country:US
Practice Address - Phone:718-422-5023
Practice Address - Fax:718-422-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217486261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical