1295845766 NPI number — MYMICHIGAN MEDICAL CENTER SAULT

Table of content: HAE-KYOUNG PARK M.D. (NPI 1871519132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295845766 NPI number — MYMICHIGAN MEDICAL CENTER SAULT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYMICHIGAN MEDICAL CENTER SAULT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MYMICHIGAN DIALYSIS SERVICES
Provider Other Organization Name Type Code:
3
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:
1295845766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 OSBORN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAULT SAINTE MARIE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49783-1884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 OSBORN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAULT SAINTE MARIE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49783-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-253-1009
Provider Business Practice Location Address Fax Number:
906-635-7872
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KALCHIK
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
906-635-4456

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40-3501500 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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