=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700486511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK AVENUE AMBULATORY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 10/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737 PARK AVE FRNT 1B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-4248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-433-0737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1775 YORK AVE APT 32A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10128-6921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-503-1607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FACILITY DIRECTOR
-----------------------------------------------------
Name | SHANALEE ACKERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-433-0737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------