Provider Demographics
NPI:1831246826
Name:PARK AVENUE ASSOCIATES IN INTERNAL MEDICINE, LTD
Entity type:Organization
Organization Name:PARK AVENUE ASSOCIATES IN INTERNAL MEDICINE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-926-4445
Mailing Address - Street 1:767 PARK AVE W
Mailing Address - Street 2:SUITE 350
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2400
Mailing Address - Country:US
Mailing Address - Phone:847-926-4445
Mailing Address - Fax:847-681-0994
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 350
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-926-4445
Practice Address - Fax:847-681-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004932481OtherBLUE CROSS BLUE SHIELD ID
ILDD5569Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
ILA58235Medicare UPIN
ILG55335Medicare UPIN
IL212153Medicare ID - Type Unspecified