MEDICARE: MR. BYUNG CHAN BAE RN

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
1	163W00000X	Registered Nurse	641728-1	NY

General Provider Information

NPI Number	:	1588956775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BYUNG CHAN BAE RN

Provider Business Mailing Address
First Line	:	4142 ELBERTSON ST
Second Line	:	APT. 302
City	:	ELMHURST
State	:	NY
Zip	:	11373-1620
Country	:	US
Telephone Number	:	610-507-2451
Fax Number	:

Provider Business Practice Location Address
First Line	:	4142 ELBERTSON ST
Second Line	:	APT. 302
City	:	ELMHURST
State	:	NY
Zip	:	11373-1620
Country	:	US
Telephone Number	:	610-507-2451
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	05/06/2011

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