Basic Information
Provider Information | |||||||||
NPI: | 1629088711 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARK AVENUE SENIOR MEDICINE, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 BARKER AVE | ||||||||
Address2: | 4TH FLOOR | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106011509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149497900 | ||||||||
FaxNumber: | 9149491245 | ||||||||
Practice Location | |||||||||
Address1: | 3 BARKER AVE | ||||||||
Address2: | 4TH FLOOR | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106011509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149497900 | ||||||||
FaxNumber: | 9149491245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAPLAN | ||||||||
AuthorizedOfficialFirstName: | MITCHEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING CONTROL | ||||||||
AuthorizedOfficialTelephone: | 9149491199 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.