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Organization
PRO FORM SPORTS MEDICINE AND WELLNESS ASSOCIATES
Active
Organization
PRO FORM SPORTS MEDICINE AND WELLNESS ASSOCIATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TAE KEUN PARK MD (PARTNER)
(646) 489-5640
Entity
Organization
Contact information
Practice address
201 ROUTE 17, 11TH FLOOR, RUTHERFORD, NJ 07070-2574
(201) 549-8846
(201) 549-8839
Mailing address
201 ROUTE 17, 11TH FLOOR, RUTHERFORD, NJ 07070-2574
(201) 549-8846
(201) 549-8839
Taxonomy
Speciality
Code
Description
License number
State
207PS0010X
Sports Medicine (Emergency Medicine) Physician
Primary
25MA08835000
NJ
Other
Enumeration date
12/20/2010
Last updated
12/20/2010
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