Basic Information
| Provider Information | |||||||||
| NPI: | 1255362653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK MEDICAL ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10755 FALLS RD STE 200 | ||||||||
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| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934520 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10755 FALLS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105837111 | ||||||||
| FaxNumber: | 4105837128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | NEWMAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4105837120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 117703600 | 05 | MD | MEDICAID |