Provider Demographics
NPI:1104865849
Name:CHAN PARK MD INC
Entity Type:Organization
Organization Name:CHAN PARK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:HOON
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-762-2728
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:905 VICTORY HWY
Mailing Address - City:SLATERSVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02876
Mailing Address - Country:US
Mailing Address - Phone:401-762-2728
Mailing Address - Fax:401-762-0473
Practice Address - Street 1:905 VICTORY HIGHWAY
Practice Address - Street 2:
Practice Address - City:SLATERSVILLE
Practice Address - State:RI
Practice Address - Zip Code:02876
Practice Address - Country:US
Practice Address - Phone:401-762-2728
Practice Address - Fax:401-762-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD5083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI12601OtherBLUE CROSS BLUE SHIELD
RI9001260Medicaid
RI001727OtherBCBS BLUE CHIP
404332OtherTUFTS
AA26737OtherHAVARD PILGRIM
MA0101561OtherEVERCARE
0100118OtherUNITED HEALTHCARE
AA26737OtherHAVARD PILGRIM