Healthcare Provider Details

I. General information

NPI: 1578517991
Provider Name (Legal Business Name): PHYSICAL MEDICINE AND REHABILITATION CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GRAND AVE FIRST FLOOR
ENGLEWOOD NJ
07631-4967
US

IV. Provider business mailing address

500 GRAND AVE FIRST FLOOR
ENGLEWOOD NJ
07631-4967
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-2277
  • Fax: 201-567-2639
Mailing address:
  • Phone: 201-567-2277
  • Fax: 201-567-2639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MB07455100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB07455100
License Number StateNJ

VIII. Authorized Official

Name: DR. SHERRY S GHOSH
Title or Position: DOCTOR OF OSTEOPATHIC MEDICINE
Credential: D.O
Phone: 201-567-2277