Provider Demographics
NPI:1386685162
Name:PARK MEDICAL GROUP PA
Entity Type:Organization
Organization Name:PARK MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNNQUELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-784-0123
Mailing Address - Street 1:24 ELM ST
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1902
Mailing Address - Country:US
Mailing Address - Phone:201-784-0123
Mailing Address - Fax:
Practice Address - Street 1:24 ELM ST
Practice Address - Street 2:
Practice Address - City:HARRINGTON PARK
Practice Address - State:NJ
Practice Address - Zip Code:07640-1902
Practice Address - Country:US
Practice Address - Phone:201-784-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05743400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0048302001OtherKEYSTONE GROUP #
NJ0048302002OtherAMERIHEALTH GROUP # T
NJ0048302004OtherAMERIHEALTH GROUP # NV
NJCB3927OtherRRMDCR GROUP #
NJ0048302001OtherAMERIHEALTH GROUP # HP
NJ7298803Medicaid
NJ0048302001OtherAMERIHEALTH GROUP # HP