1275532996 NPI number — DR. CHARLES C SUNG MD

Table of content: (NPI 1578624599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275532996 NPI number — DR. CHARLES C SUNG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNG
Provider First Name:
CHARLES
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275532996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 N DELAWARE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-7750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-736-5550
Provider Business Mailing Address Fax Number:
509-737-8281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 N DELAWARE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-7750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-736-5550
Provider Business Practice Location Address Fax Number:
509-737-8281
Provider Enumeration Date:
07/14/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD21609 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: MD36139 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MD36139 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1104926 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130346 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123380 . This is a "LABOR AND INDUSTERIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MD21609 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".