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NPI Code Detail

MEDICARE: KYOUNG SOO BAE M.D.

MEDICARE: KYOUNG SOO BAE M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician4301031350MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11006439OTHERMIMCLAREN HEALTH
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
30H26188OTHERMIBCBS PROVIDER NUMBER
40Q26008OTHERMIBCBS PROVIDER NUMBER
5110922OTHERMIGREAT LAKES HEALTH

General Provider Information

NPI Number : 1033114848
Entity Type Code : Individual
Provider Name (Legal Business Name) : KYOUNG SOO BAE M.D.
Provider Business Mailing Address
First Line : 36175 HARPER AVE
Second Line :
City : CLINTON TOWNSHIP
State : MI
Zip : 48035-3274
Country : US
Telephone Number : 586-741-3772
Fax Number : 586-741-4604
Provider Business Practice Location Address
First Line : 36175 HARPER AVE
Second Line :
City : CLINTON TOWNSHIP
State : MI
Zip : 48035-3274
Country : US
Telephone Number : 586-741-3772
Fax Number : 586-741-4604
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2005
Last Update Date : 04/20/2008

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Directions to “ KYOUNG SOO BAE M.D.” Practice Location

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