Provider Demographics
NPI:1063647980
Name:PALISADES PARK PAIN & REHABILITATION MEDICINE, PA
Entity Type:Organization
Organization Name:PALISADES PARK PAIN & REHABILITATION MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WONIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-944-1124
Mailing Address - Street 1:784 GRAND AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1043
Mailing Address - Country:US
Mailing Address - Phone:201-944-1124
Mailing Address - Fax:201-699-0406
Practice Address - Street 1:784 GRAND AVE STE 301
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1043
Practice Address - Country:US
Practice Address - Phone:201-944-1124
Practice Address - Fax:201-699-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58515207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G07466Medicare UPIN