Basic Information
| Provider Information | |||||||||
| NPI: | 1578698908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOODSIDE MEDICAL REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14370 SANFORD AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188866268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14370 SANFORD AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188866268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | JAE | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7189865841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 130080-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.