Central Park Physical Medicine PC

Primary specialty

SpecialistTaxonomy code 174400000X

License

194218-1 Issued in NY

Legal business name

CENTRAL PARK PHYSICAL MEDICINE PC

Practice address

21714 Merrick Blvd
Laurelton, NY 11413-1917

Phone

(347) 270-8353

Fax

(347) 826-1917

NPI assigned

Mar 29, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Samuel Michael Theagene, MDNPI 1518928167

Title

Owner

Phone

(347) 270-8353

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Samuel Michael Theagene, MD

  • Physical Medicine & Rehabilitation Physician
  • Laurelton, NY
  • NPI 1518928167
  Medicare reassignment Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1269820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1427673600000",
    "number": "1174848501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21714 MERRICK BLVD",
            "city": "LAURELTON",
            "state": "NY",
            "postal_code": "114131917",
            "telephone_number": "347-270-8353",
            "fax_number": "347-826-1917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21714 MERRICK BLVD",
            "city": "LAURELTON",
            "state": "NY",
            "postal_code": "114131917",
            "telephone_number": "347-270-8353",
            "fax_number": "347-826-1917"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRAL PARK PHYSICAL MEDICINE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-03-29",
        "last_updated": "2015-03-30",
        "status": "A",
        "authorized_official_last_name": "THEAGENE",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "347-270-8353",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "NY",
            "license": "194218-1",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF NY EDUCATION DEPT",
            "identifier": "194218-1",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Camille Care Solutions Medical Supplies LLC
• Janine Canton
• Sorivel Carrasquillo
• Angela Cashwell, LCSW
• Marie Casimir
• Donna Cerrio, LMSW
• Ceoneah Charles, LPN
• Crystal Charles
• Judith Charles
• Winston Charles, LPN

• Specialist in Laurelton, NY
• Providers in Laurelton, NY by specialty
• Specialist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.