Provider Demographics
NPI:1821304288
Name:PARK OB GYN
Entity Type:Organization
Organization Name:PARK OB GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANKEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-7660
Mailing Address - Street 1:16570 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1106
Mailing Address - Country:US
Mailing Address - Phone:586-263-7660
Mailing Address - Fax:586-263-4727
Practice Address - Street 1:16570 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1106
Practice Address - Country:US
Practice Address - Phone:586-263-7660
Practice Address - Fax:586-263-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037049207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518995869Medicaid
MI4301037049OtherLICENSE
MI4301037049OtherLICENSE
MI=========OtherTAX ID