Provider Demographics
NPI:1205871001
Name:PARK AVENUE DERMATOLOGY PA
Entity type:Organization
Organization Name:PARK AVENUE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHMIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-541-0315
Mailing Address - Street 1:906 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4120
Mailing Address - Country:US
Mailing Address - Phone:904-541-0315
Mailing Address - Fax:904-541-0316
Practice Address - Street 1:906 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4120
Practice Address - Country:US
Practice Address - Phone:904-541-0315
Practice Address - Fax:904-541-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 4926207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9927Medicare UPIN