Provider Demographics
NPI:1477812956
Name:PAK, KIRK JIHYON (MD, PHD, MSC)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:JIHYON
Last Name:PAK
Suffix:
Gender:M
Credentials:MD, PHD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1104 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978
Practice Address - Country:US
Practice Address - Phone:219-866-5141
Practice Address - Fax:219-866-3234
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076965A207R00000X, 208M00000X, 208M00000X
LAMD.207561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300006000Medicaid
000001195932OtherANTHEM
LA2196472Medicaid
MS05809560Medicaid