Provider Demographics
NPI:1427252626
Name:PARK SOUTH MEDICAL PLLC
Entity type:Organization
Organization Name:PARK SOUTH MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZRATTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-892-2201
Mailing Address - Street 1:1545 UNIONPORT RD
Mailing Address - Street 2:PARK SOUTH MEDICAL
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-7714
Mailing Address - Country:US
Mailing Address - Phone:718-892-2201
Mailing Address - Fax:718-828-9663
Practice Address - Street 1:1545 UNIONPORT RD
Practice Address - Street 2:PARK SOUTH MEDICAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7714
Practice Address - Country:US
Practice Address - Phone:718-892-2201
Practice Address - Fax:718-828-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWWT411Medicare PIN