Provider Demographics
NPI:1881630341
Name:MANSUK CHAE MD PC
Entity Type:Organization
Organization Name:MANSUK CHAE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING AGENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANSUK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-383-4833
Mailing Address - Street 1:7445 ALLEN RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1963
Mailing Address - Country:US
Mailing Address - Phone:313-383-4833
Mailing Address - Fax:
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:SUITE 180
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1963
Practice Address - Country:US
Practice Address - Phone:313-383-4833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032356207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1829417Medicare ID - Type Unspecified