Basic Information
| Provider Information | |||||||||
| NPI: | 1376777847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665075244 | ||||||||
| FaxNumber: | 8558514405 | ||||||||
| Practice Location | |||||||||
| Address1: | 6511 SPRINGBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | RHINEBECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453312098 | ||||||||
| FaxNumber: | 8453312814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 04/17/2015 | ||||||||
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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 | 207L00000X | 4301 094 085 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 271251 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 03627401 | 05 | NY | MEDICAID |