Healthcare Provider Details

I. General information

NPI: 1487100350
Provider Name (Legal Business Name): PARK ALLERGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W CENTRE AVE
PORTAGE MI
49024-5304
US

IV. Provider business mailing address

430 W CENTRE AVE
PORTAGE MI
49024-5304
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-6673
  • Fax: 269-324-5594
Mailing address:
  • Phone: 269-321-6673
  • Fax: 269-324-5594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL PARK
Title or Position: OWNER
Credential: MD
Phone: 269-321-6673