=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720337900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK AVENUE FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2012
-----------------------------------------------------
Last Update Date | 09/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 ARCADE ST
-----------------------------------------------------
City | ST PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-771-5388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 ARCADE ST
-----------------------------------------------------
City | ST PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-771-5388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | KAREN LEE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 651-771-5388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------