Basic Information
| Provider Information | |||||||||
| NPI: | 1578517991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL MEDICINE AND REHABILITATION CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GRAND AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015672277 | ||||||||
| FaxNumber: | 2015672639 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 GRAND AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015672277 | ||||||||
| FaxNumber: | 2015672639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 03/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | GHOSH | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR OF OSTEOPATHIC MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 2015672277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 25MB07455100 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 174400000X | 25MB07455100 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.