Provider Demographics
NPI:1891802500
Name:PAIK, MOON KI (MD)
Entity Type:Individual
Prefix:
First Name:MOON
Middle Name:KI
Last Name:PAIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28111 HOOVER
Mailing Address - Street 2:#7A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-573-0900
Mailing Address - Fax:586-573-0902
Practice Address - Street 1:28111 HOOVER RD
Practice Address - Street 2:#7A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-573-0900
Practice Address - Fax:586-573-0902
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033213207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4784698Medicaid
MI1605015361OtherBCBS
105266OtherGREAT LAKES
13531OtherCAPE
MI1605015361OtherBCNETWK
105266OtherGREAT LAKES
MI4784698Medicaid