Provider Demographics
NPI:1528038197
Name:KANG, TAI SR
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:
Last Name:KANG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S JEFFERSON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1267
Mailing Address - Country:US
Mailing Address - Phone:989-753-9000
Mailing Address - Fax:
Practice Address - Street 1:3037 SILVERWOOD DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2171
Practice Address - Country:US
Practice Address - Phone:989-753-9000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010333342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4306143Medicaid
MI4306143Medicaid