Healthcare Provider Details

I. General information

NPI: 1073208047
Provider Name (Legal Business Name): REENA PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 HAL GREER BLVD
HUNTINGTON WV
25701-3804
US

IV. Provider business mailing address

1701 N SENATE BLVD
INDIANAPOLIS IN
46202-1239
US

V. Phone/Fax

Practice location:
  • Phone: 304-526-2200
  • Fax: 304-399-1507
Mailing address:
  • Phone: 317-962-5975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36688
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01097515A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: