Healthcare Provider Details

I. General information

NPI: 1053352468
Provider Name (Legal Business Name): TRISTATE MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND AVE SUITE 505
PALISADES PARK NJ
07650-1076
US

IV. Provider business mailing address

21 GRAND AVE SUITE 505
PALISADES PARK NJ
07650-1076
US

V. Phone/Fax

Practice location:
  • Phone: 201-313-4840
  • Fax: 201-313-9353
Mailing address:
  • Phone: 201-313-4840
  • Fax: 201-313-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMA071859
License Number StateNJ

VIII. Authorized Official

Name: DR. HONG SIK PAK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-313-4840