Healthcare Provider Details

I. General information

NPI: 1841701372
Provider Name (Legal Business Name): REJUV AESTHETIC GYNECOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 DURHAM AVE STE 1A
SOUTH PLAINFIELD NJ
07080-2555
US

IV. Provider business mailing address

285 DURHAM AVE STE 1A BLDG 6
SOUTH PLAINFIELD NJ
07080-2546
US

V. Phone/Fax

Practice location:
  • Phone: 732-338-0228
  • Fax: 201-485-6792
Mailing address:
  • Phone: 732-338-0228
  • Fax: 201-485-6792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number25MB09742100
License Number StateNJ

VIII. Authorized Official

Name: DR. EDSEL ANTONIO
Title or Position: PROVIDER
Credential: DO
Phone: 732-841-0772