Provider Demographics
NPI:1497769988
Name:WAILEA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:WAILEA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-875-9095
Mailing Address - Street 1:161 WAILEA IKE PL
Mailing Address - Street 2:B-102
Mailing Address - City:WAILEA
Mailing Address - State:HI
Mailing Address - Zip Code:96753-6521
Mailing Address - Country:US
Mailing Address - Phone:808-875-9095
Mailing Address - Fax:808-875-9098
Practice Address - Street 1:161 WAILEA IKE PL
Practice Address - Street 2:#B102
Practice Address - City:WAILEA
Practice Address - State:HI
Practice Address - Zip Code:96753-6521
Practice Address - Country:US
Practice Address - Phone:808-875-9095
Practice Address - Fax:808-875-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3915207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI045506-02Medicaid
HI045506-02Medicaid
HI1497769988Medicare PIN