Basic Information
| Provider Information | |||||||||
| NPI: | 1841259512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKWAY MEDICAL GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 391 EASTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112164153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186131600 | ||||||||
| FaxNumber: | 7186131666 | ||||||||
| Practice Location | |||||||||
| Address1: | 391 EASTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112164153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186131600 | ||||||||
| FaxNumber: | 7186131666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEON | ||||||||
| AuthorizedOfficialFirstName: | MARIE LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7186131600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 196577 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01682782 | 05 | NY | MEDICAID |