Provider Demographics
NPI:1841701372
Name:REJUV AESTHETIC GYNECOLOGY PA
Entity type:Organization
Organization Name:REJUV AESTHETIC GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONIO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-841-0772
Mailing Address - Street 1:285 DURHAM AVE
Mailing Address - Street 2:STE 1A BLDG 6
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2546
Mailing Address - Country:US
Mailing Address - Phone:732-338-0228
Mailing Address - Fax:201-485-6792
Practice Address - Street 1:285 DURHAM AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2555
Practice Address - Country:US
Practice Address - Phone:732-338-0228
Practice Address - Fax:201-485-6792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09742100207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty