1912255746 NPI number — MOON PAIK MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912255746 NPI number — MOON PAIK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOON PAIK MD
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:
1912255746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28111 HOOVER RD
Provider Second Line Business Mailing Address:
UNIT 7A
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-4153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-573-0902
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28111 HOOVER RD
Provider Second Line Business Practice Location Address:
UNIT 7A
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-4153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-573-0902
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
NEVILLE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
586-226-3671

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  4301033213 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4784698 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com