Healthcare Provider Details

I. General information

NPI: 1205094562
Provider Name (Legal Business Name): PARK AVE AMBULATORY MEDICAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COURT ST SUITE# 3
BROOKLYN NY
11231-4353
US

IV. Provider business mailing address

360 COURT ST SUITE# 3
BROOKLYN NY
11231-4353
US

V. Phone/Fax

Practice location:
  • Phone: 718-422-5023
  • Fax: 718-422-5025
Mailing address:
  • Phone: 718-422-5023
  • Fax: 718-422-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number217486
License Number StateNY

VIII. Authorized Official

Name: DR. VADIM KUSHNERIK
Title or Position: SURGICAL DIRECTOR
Credential: MD
Phone: 718-422-5023