Provider Demographics
NPI:1700828969
Name:WON CHAE MD PC
Entity Type:Organization
Organization Name:WON CHAE MD PC
Other - Org Name:FARMBROOK RADIOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING BILLING
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-352-9525
Mailing Address - Street 1:29829 TELEGRAPH RD
Mailing Address - Street 2:SUITE L103
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1376
Mailing Address - Country:US
Mailing Address - Phone:248-352-9525
Mailing Address - Fax:248-357-2959
Practice Address - Street 1:29829 TELEGRAPH RD
Practice Address - Street 2:SUITE L103
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1376
Practice Address - Country:US
Practice Address - Phone:248-352-9525
Practice Address - Fax:248-357-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002085N0904X, 2085R0202X, 2085R0204X, 2085U0001X
MI261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF372090OtherBLUE SHIELD GROUP PIN
MIRA630034OtherMCARE GROUP PIN
MI506377OtherCARE CHOICES GROUP PIN
MIQMXPR0014590OtherMOLINA
MI1007775-001OtherWELLNESS PLAN GROUP PIN
MI132484OtherGREAT LAKE HEALTH PLAN
MI5101OtherCAPE HEALTH PLAN GROUP
MI5006540OtherAETNA GROUP PIN
MI1007775-001OtherWELLNESS PLAN GROUP PIN
MI0M38520Medicare PIN
MI5006540OtherAETNA GROUP PIN