=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780684167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA NICOLA PARK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 MOUNT KEMBLE AVE THEBAUD BLDG. 4TH FLOOR
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-5155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-796-3600
-----------------------------------------------------
Fax | 973-267-3144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 MOUNT KEMBLE AVE THEBAUD BLDG. 4TH FLOOR
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-5155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-796-3600
-----------------------------------------------------
Fax | 973-267-3144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 25MA07753800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------