Healthcare Provider Details

I. General information

NPI: 1942737697
Provider Name (Legal Business Name): BRIAN PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 04/26/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMC - PULMONARY AND CRITICAL CARE MEDICINE 3200 MACCORKLE AVE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

COOPER HEALTH GRADUATE MEDICAL EDUCATION ONE COOPER PLZ
CAMDEN NJ
08103
US

V. Phone/Fax

Practice location:
  • Phone: 201-978-9388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD468574
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number33603
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number25MA1085990
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: