MEDICARE: PARK AVENUE PHYSICIANS 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	2084P0804X	Child & Adolescent Psychiatry Physician
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1881102267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK AVENUE PHYSICIANS PC

Provider Business Mailing Address
First Line	:	5 W 86TH ST APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:	917-732-3990
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 W 86TH ST APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:	917-732-3990
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ELEEZA MANTONE
Credential	:
Telephone Number	:	917-732-3990

Provider Enumeration Date	:	01/19/2018
Last Update Date	:	01/27/2018

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