Provider Demographics
NPI:1003914425
Name:PARK, MEEJUNG JANE (PT)
Entity Type:Individual
Prefix:
First Name:MEEJUNG
Middle Name:JANE
Last Name:PARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SAINT REGIS CT
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5616
Mailing Address - Country:US
Mailing Address - Phone:630-748-9670
Mailing Address - Fax:
Practice Address - Street 1:2001 MIDWEST RD
Practice Address - Street 2:STE 302
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1343
Practice Address - Country:US
Practice Address - Phone:630-620-9066
Practice Address - Fax:630-620-8570
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-010605225100000X
CAPT25055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26357Medicare PIN
ILK26358Medicare PIN
CAWPT25055BMedicare PIN
ILIL4123001Medicare PIN