Basic Information
| Provider Information | |||||||||
| NPI: | 1235186651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARK | ||||||||
| OtherFirstName: | PAUL | ||||||||
| OtherMiddleName: | F | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2147 RIVERCHASE OFFICE RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352441836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2059820278 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MONTGOMERY HWY | ||||||||
| Address2: | STE# 100 | ||||||||
| City: | VESTAVIA HILLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352161842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054212114 | ||||||||
| FaxNumber: | 2052017775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 16962 | AL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000031339 | 05 | AL | MEDICAID | 51046120 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 117861 | 01 | AL | MEDICAID/EDS AFC VESTAVIA HILLS | OTHER | 102I027856 | 01 | AL | MEDICARE PTAN # ESTABLISH 2009 | OTHER | 515-97129 | 01 | AL | AL BCBS # AFC VESTAVIA | OTHER | 020050785 | 01 | AL | RAILROAD MEDICARE | OTHER |