Healthcare Provider Details

I. General information

NPI: 1487652889
Provider Name (Legal Business Name): PARKSIDE HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 PARKSIDE AVE STE 23
EWING NJ
08638-2946
US

IV. Provider business mailing address

1450 PARKSIDE AVE STE 23
EWING NJ
08638-2946
US

V. Phone/Fax

Practice location:
  • Phone: 609-882-5200
  • Fax: 609-882-0370
Mailing address:
  • Phone: 609-882-5200
  • Fax: 609-882-0370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OBASI A. CHUKWUNENYE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 609-882-5200