Healthcare Provider Details

I. General information

NPI: 1639552144
Provider Name (Legal Business Name): PARK WEST SURGICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CENTRAL PARK W
NEW YORK NY
10023-6055
US

IV. Provider business mailing address

75 S DEAN ST
ENGLEWOOD NJ
07631-3512
US

V. Phone/Fax

Practice location:
  • Phone: 201-871-4000
  • Fax: 201-608-6852
Mailing address:
  • Phone: 201-862-9300
  • Fax: 201-608-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ARGYRIOS MAVROGIORGIS
Title or Position: REGISTERED AGENT
Credential:
Phone: 201-862-9300