Provider Demographics
NPI:1912114786
Name:DEPARTMENT OF PHYSICAL MEDICINE AND REHAB
Entity type:Organization
Organization Name:DEPARTMENT OF PHYSICAL MEDICINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE, MD
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-734-7600
Mailing Address - Street 1:4 PRINCESS RD
Mailing Address - Street 2:SUITE #207
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-734-7600
Mailing Address - Fax:609-844-1092
Practice Address - Street 1:79 BAYARD LN
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-3045
Practice Address - Country:US
Practice Address - Phone:609-734-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7227604Medicaid