Provider Demographics
NPI:1093080871
Name:PALISADES PARK MEDICINE, P.C.
Entity Type:Organization
Organization Name:PALISADES PARK MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYUNGKON
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-638-8156
Mailing Address - Street 1:340 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2618
Mailing Address - Country:US
Mailing Address - Phone:201-592-1112
Mailing Address - Fax:
Practice Address - Street 1:340 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-2618
Practice Address - Country:US
Practice Address - Phone:201-592-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2MA05329300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7179405Medicaid
NJF35218Medicare PIN
NJF35218Medicare UPIN