MEDICARE: PARK WEST HEALTH SYSTEM, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073914206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK WEST HEALTH SYSTEM, INC.

Provider Business Mailing Address
First Line	:	4601 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7553
Country	:	US
Telephone Number	:	410-542-7800
Fax Number	:	410-542-3014

Provider Business Practice Location Address
First Line	:	4601 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7553
Country	:	US
Telephone Number	:	443-884-7577
Fax Number	:	667-239-3121

Authorized Official
Title or Position	:	CFO
Name	:	ELIZABETH LEE
Credential	:
Telephone Number	:	410-542-7800

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	11/03/2014

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