=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245628163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK VASCULAR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 12/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 990 E 23RD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11210-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-258-2437
-----------------------------------------------------
Fax | 718-228-4233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 990 E 23RD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11210-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-258-2437
-----------------------------------------------------
Fax | 718-228-4233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER, PHYSICIAN, VASCULAR TECH
-----------------------------------------------------
Name | DR. MICHAEL FUCHS
-----------------------------------------------------
Credential | MD, RVT
-----------------------------------------------------
Telephone | 718-853-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 126307
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------