=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447533773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK AVE MEDICAL CENTRE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2011
-----------------------------------------------------
Last Update Date | 09/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 535 GETTY AVE SUITE 3
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-239-4808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1367 RATZER RD
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-239-4808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPREITER
-----------------------------------------------------
Name | DR. RAFATH K HUMERA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 862-239-4808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA08760600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------