Healthcare Provider Details

I. General information

NPI: 1588855324
Provider Name (Legal Business Name): CHAN-SHIK PARK MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST BWH, DEPARTMENT OF PATHOLOGY
BOSTON MA
02115-6110
US

IV. Provider business mailing address

75 FRANCIS ST BWH, DEPARTMENT OF PATHOLOGY
BOSTON MA
02115-6110
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-7510
  • Fax:
Mailing address:
  • Phone: 617-732-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License Number233065
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: