Healthcare Provider Details

I. General information

NPI: 1174764724
Provider Name (Legal Business Name): GYE YOUNG PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GYE Y PARK M.D.

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST MC719 ROOM 920N
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

840 S WOOD ST MC719 ROOM 920N
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-8039
  • Fax: 312-996-4665
Mailing address:
  • Phone: 312-996-8039
  • Fax: 312-996-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36123031
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36123031
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: