Provider Demographics
NPI:1679939417
Name:PARK, KYUHUN
Entity Type:Individual
Prefix:
First Name:KYUHUN
Middle Name:
Last Name:PARK
Suffix:
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 1:2540 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-2046
Mailing Address - Country:US
Mailing Address - Phone:708-452-7275
Mailing Address - Fax:708-452-7295
Practice Address - Street 1:2540 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-2046
Practice Address - Country:US
Practice Address - Phone:708-452-7275
Practice Address - Fax:708-452-7295
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL090.005328284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital