Provider Demographics
NPI:1326185943
Name:CHUNG, POLLY CLARE (RD CDE)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:CLARE
Last Name:CHUNG
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 LONDON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3536
Mailing Address - Country:US
Mailing Address - Phone:248-524-9547
Mailing Address - Fax:248-524-9547
Practice Address - Street 1:3031 WEST GRAND BOULEVARD
Practice Address - Street 2:HENRY FORD HOSPITAL ENDOCRINOLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3141
Practice Address - Country:US
Practice Address - Phone:313-916-2127
Practice Address - Fax:313-916-8343
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITO BE ISSUED 2007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN54380002Medicare ID - Type UnspecifiedREGISTERED DIETITIAN