Provider Demographics
NPI:1912199613
Name:SALEM MEDICAL OFFICE PC
Entity Type:Organization
Organization Name:SALEM MEDICAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNG KI
Authorized Official - Middle Name:
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-463-6134
Mailing Address - Street 1:15615 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5015
Mailing Address - Country:US
Mailing Address - Phone:718-463-6134
Mailing Address - Fax:
Practice Address - Street 1:15615 35TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5015
Practice Address - Country:US
Practice Address - Phone:718-463-6134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190445-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01727724Medicaid
NY01727724Medicaid