Healthcare Provider Details

I. General information

NPI: 1356300487
Provider Name (Legal Business Name): SANGTAE PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9711 SKOKIE BLVD STE H
SKOKIE IL
60077-1384
US

IV. Provider business mailing address

9711 SKOKIE BLVD STE H
SKOKIE IL
60077-1384
US

V. Phone/Fax

Practice location:
  • Phone: 847-676-2400
  • Fax: 847-676-2485
Mailing address:
  • Phone: 847-676-2400
  • Fax: 847-676-2485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberM0855
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036119572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: