Provider Demographics
NPI:1235169459
Name:MIN, TAE CHEOL (MD)
Entity Type:Individual
Prefix:DR
First Name:TAE
Middle Name:CHEOL
Last Name:MIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:877-771-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030898L174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010440280003Medicaid
PA1044028Medicaid
PA5000059565Medicare NSC
PA0010440280003Medicaid
PA0010440280003Medicaid