MEDICARE: PARK SOUTH MEDICAL PLLC

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	207R00000X	Internal Medicine Physician	146894	NY

General Provider Information

NPI Number	:	1427252626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK SOUTH MEDICAL PLLC

Provider Business Mailing Address
First Line	:	1545 UNIONPORT RD
Second Line	:	PARK SOUTH MEDICAL
City	:	BRONX
State	:	NY
Zip	:	10462-7714
Country	:	US
Telephone Number	:	718-892-2201
Fax Number	:	718-828-9663

Provider Business Practice Location Address
First Line	:	1545 UNIONPORT RD
Second Line	:	PARK SOUTH MEDICAL
City	:	BRONX
State	:	NY
Zip	:	10462-7714
Country	:	US
Telephone Number	:	718-892-2201
Fax Number	:	718-828-9663

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MONTE EZRATTY
Credential	:	M.D.
Telephone Number	:	718-892-2201

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	01/03/2008

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