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General NPI Number Information
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NPI Number | 1184795700
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Entity Type | Organization
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Legal Business Name | THE PARK MEDICAL GROUP, PA
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 163 PARIS AVE
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City | NORTHVALE
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State | NJ
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Zip | 07647-2028
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Country | US
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Telephone | 201-768-9090
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Fax | 201-768-9009
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Provider Business Mailing Address
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Address Line | 24 ELM ST
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City | HARRINGTON PARK
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State | NJ
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Zip | 07640-1902
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Country | US
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Telephone | 201-784-0123
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Fax | 201-784-0065
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Authorized Official
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Title or Position | DELEGATED OFFICIAL
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Name | STEPHEN BRUNNQUELL
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Credential |
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Telephone | 201-784-0123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25MA05743400
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License Number State | NJ
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