Provider Demographics
NPI:1255362653
Name:PARK MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:PARK MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAMEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:104-583-7112
Mailing Address - Street 1:10755 FALLS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD STE 200
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4520
Practice Address - Country:US
Practice Address - Phone:410-583-7111
Practice Address - Fax:410-583-7128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD117703600Medicaid
MDH694Medicare ID - Type Unspecified