MEDICARE: CENTRAL PARK PHYSICAL MEDICINE PC

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	174400000X	Specialist	194218-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	194218-1	OTHER	NY	STATE OF NY EDUCATION DEPT

General Provider Information

NPI Number	:	1174848501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL PARK PHYSICAL MEDICINE PC

Provider Business Mailing Address
First Line	:	21714 MERRICK BLVD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-1917
Country	:	US
Telephone Number	:	347-270-8353
Fax Number	:	347-826-1917

Provider Business Practice Location Address
First Line	:	21714 MERRICK BLVD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-1917
Country	:	US
Telephone Number	:	347-270-8353
Fax Number	:	347-826-1917

Authorized Official
Title or Position	:	OWNER
Name	:	SAMUEL MICHAEL THEAGENE
Credential	:	MD
Telephone Number	:	347-270-8353

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	03/30/2015

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