1932196219 NPI number — DR. GRACE SOO KYUNG BAI MD

Table of content: DR. GRACE SOO KYUNG BAI MD (NPI 1932196219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932196219 NPI number — DR. GRACE SOO KYUNG BAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAI
Provider First Name:
GRACE
Provider Middle Name:
SOO KYUNG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1932196219
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9669 KENTON AVE
Provider Second Line Business Mailing Address:
#409
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-933-0800
Provider Business Mailing Address Fax Number:
855-329-4224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9669 KENTON AVE
Provider Second Line Business Practice Location Address:
#409
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-1266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-933-0800
Provider Business Practice Location Address Fax Number:
855-329-4224
Provider Enumeration Date:
10/03/2005

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: 207W00000X , with the licence number:  036103366 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01633731 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036103366 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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