Healthcare Provider Details

I. General information

NPI: 1043684517
Provider Name (Legal Business Name): SEONGHUN JEONG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2015
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1283 W DUNDEE RD
BUFFALO GROVE IL
60089-4009
US

IV. Provider business mailing address

21502 46TH AVE FL 2
BAYSIDE NY
11361-3437
US

V. Phone/Fax

Practice location:
  • Phone: 847-632-9919
  • Fax: 773-585-6201
Mailing address:
  • Phone: 213-309-8179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number045412
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070021866
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: