Healthcare Provider Details

I. General information

NPI: 1821246869
Provider Name (Legal Business Name): THE PARK CLINIC FOR COSMETIC AND RECONSTRUCTIVE SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3153 DAUPHIN ST
MOBILE AL
36606-4061
US

IV. Provider business mailing address

PO BOX 852047
MOBILE AL
36685-2047
US

V. Phone/Fax

Practice location:
  • Phone: 251-340-6600
  • Fax:
Mailing address:
  • Phone: 251-340-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD.28938
License Number StateAL

VIII. Authorized Official

Name: CHRISTOPHER A PARK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 251-340-6600