1194769810 NPI number — DR. SUNG TAE BYUN MD

Table of content: DR. SUNG TAE BYUN MD (NPI 1194769810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194769810 NPI number — DR. SUNG TAE BYUN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BYUN
Provider First Name:
SUNG
Provider Middle Name:
TAE
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:
1194769810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 VERONICA S SHOEMAKER BLVD
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33916-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-8200
Provider Business Mailing Address Fax Number:
239-278-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8787 BRYAN DAIRY RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33777-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-397-9641
Provider Business Practice Location Address Fax Number:
727-393-4194
Provider Enumeration Date:
06/15/2006

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: 207RH0003X , with the licence number:  ME72379 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X , with the licence number: ME72379 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0000X , with the licence number: ME72379 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 261657200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 830003154 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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