Provider Demographics
NPI:1447533773
Name:PARK AVE MEDICAL CENTRE LLC
Entity type:Organization
Organization Name:PARK AVE MEDICAL CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPREITER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFATH
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUMERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:862-239-4808
Mailing Address - Street 1:1367 RATZER RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2429
Mailing Address - Country:US
Mailing Address - Phone:862-239-4808
Mailing Address - Fax:
Practice Address - Street 1:535 GETTY AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2105
Practice Address - Country:US
Practice Address - Phone:862-239-4808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08760600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty