Provider Demographics
NPI:1811921281
Name:PARKSTONE MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:PARKSTONE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-229-2022
Mailing Address - Street 1:2304 N BROAD STREET
Mailing Address - Street 2:SPACE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132
Mailing Address - Country:US
Mailing Address - Phone:215-229-2022
Mailing Address - Fax:215-229-2048
Practice Address - Street 1:2304 N BROAD STREET
Practice Address - Street 2:SPACE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:215-229-2022
Practice Address - Fax:215-229-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023038E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000807374OtherHIGHMARK BLUE SHIELD ID