Provider Demographics
NPI:1235432972
Name:PRO FORM SPORTS MEDICINE AND WELLNESS ASSOCIATES
Entity Type:Organization
Organization Name:PRO FORM SPORTS MEDICINE AND WELLNESS ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE KEUN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-489-5640
Mailing Address - Street 1:201 ROUTE 17
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2574
Mailing Address - Country:US
Mailing Address - Phone:201-549-8846
Mailing Address - Fax:201-549-8839
Practice Address - Street 1:201 ROUTE 17
Practice Address - Street 2:11TH FLOOR
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2574
Practice Address - Country:US
Practice Address - Phone:201-549-8846
Practice Address - Fax:201-549-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08835000207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty