Provider Demographics
NPI:1043711203
Name:PANDA PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:PANDA PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERRANTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-455-1375
Mailing Address - Street 1:904 DEAL RD APT 12
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3443
Mailing Address - Country:US
Mailing Address - Phone:732-455-1375
Mailing Address - Fax:732-230-7680
Practice Address - Street 1:142 HIGHWAY 35 STE 107
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1864
Practice Address - Country:US
Practice Address - Phone:732-898-3040
Practice Address - Fax:732-531-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty