Basic Information
| Provider Information | |||||||||
| NPI: | 1033427398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK MEDICAL ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 205 | ||||||||
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| City: | MANVILLE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028380205 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 251 PARK AVE | ||||||||
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| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029052647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 09/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | CRAUSMAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8009270002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.