1104865849 NPI number — CHAN PARK MD INC

Table of content: (NPI 1104865849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104865849 NPI number — CHAN PARK MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAN PARK MD INC
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:
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:
1104865849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 177
Provider Second Line Business Mailing Address:
905 VICTORY HWY
Provider Business Mailing Address City Name:
SLATERSVILLE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-762-2728
Provider Business Mailing Address Fax Number:
401-762-0473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 VICTORY HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLATERSVILLE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-762-2728
Provider Business Practice Location Address Fax Number:
401-762-0473
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
CHAN
Authorized Official Middle Name:
HOON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
401-762-2728

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD5083 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12601 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9001260 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001727 . This is a "BCBS BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 404332 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA26737 . This is a "HAVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0101561 . This is a "EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0100118 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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