MEDICARE: PARK ALLERGY CENTER PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician

General Provider Information

NPI Number	:	1487100350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK ALLERGY CENTER PC

Provider Business Mailing Address
First Line	:	430 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5304
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:	269-324-5594

Provider Business Practice Location Address
First Line	:	430 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5304
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:	269-324-5594

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL PARK
Credential	:	MD
Telephone Number	:	269-321-6673

Provider Enumeration Date	:	08/30/2016
Last Update Date	:	08/30/2016

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Directions to “PARK ALLERGY CENTER PC ” Practice Location

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