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General NPI Number Information
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NPI Number | 1952575417
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Entity Type | Organization
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Legal Business Name | PARK AVENUE SPORTS MEDICINE & REHABILITATION PC
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Dates
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Enumeration Date | 04/16/2008
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Last Update Date | 06/05/2008
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Provider Practice Location Address
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Address Line | 110-45 QUEENS BLVD SUITE 117
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City | FOREST HILLS
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State | NY
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Zip | 11375
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Country | US
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Telephone | 718-575-5050
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Fax | 718-575-8541
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Provider Business Mailing Address
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Address Line | 11045 QUEENS BLVD 117
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City | FOREST HILLS
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State | NY
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Zip | 11375-5519
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Country | US
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Telephone | 715-575-5050
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Fax | 718-575-8541
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Authorized Official
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Title or Position | OWNER
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Name | OSKAR WEG
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Credential |
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Telephone | 718-575-5050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 169749
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License Number State | NY
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