Provider Demographics
NPI:1164619623
Name:J H PARK MD PC
Entity Type:Organization
Organization Name:J H PARK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOUNG
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-772-2600
Mailing Address - Street 1:25710 KELLY RD
Mailing Address - Street 2:STE 3
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4959
Mailing Address - Country:US
Mailing Address - Phone:586-772-2600
Mailing Address - Fax:586-772-5289
Practice Address - Street 1:25710 KELLY RD
Practice Address - Street 2:STE 3
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4959
Practice Address - Country:US
Practice Address - Phone:586-772-2600
Practice Address - Fax:586-772-5289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P18030Medicare PIN