Healthcare Provider Details

I. General information

NPI: 1841259512
Provider Name (Legal Business Name): PARKWAY MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 EASTERN PKWY
BROOKLYN NY
11216-4153
US

IV. Provider business mailing address

391 EASTERN PKWY
BROOKLYN NY
11216-4153
US

V. Phone/Fax

Practice location:
  • Phone: 718-613-1600
  • Fax: 718-613-1666
Mailing address:
  • Phone: 718-613-1600
  • Fax: 718-613-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number196577
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01682782
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. MARIE LAURA LEON
Title or Position: PARTNER
Credential: MD
Phone: 718-613-1600