Provider Demographics
NPI:1356405294
Name:YONG SOO SO, M.D., P.C.
Entity type:Organization
Organization Name:YONG SOO SO, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YONG
Authorized Official - Middle Name:SOO
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-778-0209
Mailing Address - Street 1:22001 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2708
Mailing Address - Country:US
Mailing Address - Phone:586-778-0209
Mailing Address - Fax:586-778-0202
Practice Address - Street 1:22001 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2708
Practice Address - Country:US
Practice Address - Phone:586-778-0209
Practice Address - Fax:586-778-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIYS037124208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4641238Medicaid
MI4641238Medicaid
MI0N89590Medicare PIN
MI=========OtherPRIVATE INSURANCE