Healthcare Provider Details

I. General information

NPI: 1508851304
Provider Name (Legal Business Name): PARK PRIMARY CARE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2005
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 AMBOY AVE
WOODBRIDGE NJ
07095-2960
US

IV. Provider business mailing address

PO BOX 331
COLONIA NJ
07067-0331
US

V. Phone/Fax

Practice location:
  • Phone: 732-636-6612
  • Fax: 732-636-8224
Mailing address:
  • Phone: 732-636-6612
  • Fax: 732-605-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA046971
License Number StateNJ

VIII. Authorized Official

Name: DR. JEFFREY ROSEN
Title or Position: M.D./PRESIDENT
Credential: M.D.
Phone: 732-636-6612