Provider Demographics
NPI:1972825883
Name:DR PARK'S PAIN MANAGEMENT, PC
Entity Type:Organization
Organization Name:DR PARK'S PAIN MANAGEMENT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANG
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-543-8218
Mailing Address - Street 1:1638 SCHLOSSER ST
Mailing Address - Street 2:D4 STE 1
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5650
Mailing Address - Country:US
Mailing Address - Phone:201-543-8218
Mailing Address - Fax:
Practice Address - Street 1:1638 SCHLOSSER ST
Practice Address - Street 2:D4 STE 1
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5650
Practice Address - Country:US
Practice Address - Phone:201-543-8218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07699600207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1275554610OtherNPI