Organization
CENTRAL PARK PHYSICAL MEDICINE PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL MICHAEL THEAGENE MD (OWNER)
(347) 270-8353
Entity
Organization
Contact information
Practice address
21714 MERRICK BLVD, LAURELTON, NY 11413-1917
(347) 270-8353
(347) 826-1917
Mailing address
21714 MERRICK BLVD, LAURELTON, NY 11413-1917
(347) 270-8353
(347) 826-1917
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
194218-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
194218-1
STATE OF NY EDUCATION DEPT
NY
Enumeration date
03/29/2010
Last updated
03/30/2015
Update your record
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