1184607293 NPI number — JONG MOON WOO MD

Table of content: JONG MOON WOO MD (NPI 1184607293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184607293 NPI number — JONG MOON WOO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOO
Provider First Name:
JONG
Provider Middle Name:
MOON
Provider Name Prefix Text:
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:
1184607293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 MEDICAL VILLAGE DRIVE
Provider Second Line Business Mailing Address:
#258
Provider Business Mailing Address City Name:
EDGEWOOD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-341-7246
Provider Business Mailing Address Fax Number:
859-341-7867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 QUEEN CITY AVE
Provider Second Line Business Practice Location Address:
OHIO VALLEY ANESTHESIA LLC
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-7246
Provider Business Practice Location Address Fax Number:
859-341-7867
Provider Enumeration Date:
11/22/2005

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: 207L00000X , with the licence number:  35046295W , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200413420 . This is a "INDIANA MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0499045 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000257501 . This is a "ANTHEM BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64060478 . This is a "MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".