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General NPI Number Information
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NPI Number | 1740546399
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Entity Type | Organization
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Legal Business Name | PARK AVENUE MEDICAL
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Dates
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Enumeration Date | 04/09/2012
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Last Update Date | 06/20/2022
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Provider Practice Location Address
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Address Line | 85 BARNES RD STE 202
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City | WALLINGFORD
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State | CT
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Zip | 06492
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Country | US
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Telephone | 203-309-0070
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Fax | 203-309-0071
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Provider Business Mailing Address
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Address Line | 85 BARNES RD STE 202
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City | WALLINGFORD
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State | CT
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Zip | 06492
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Country | US
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Telephone | 203-309-0070
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Fax | 203-309-0071
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | ANACE SAID
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Credential | MD
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Telephone | 203-309-0070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 044791
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License Number State | CT
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