Healthcare Provider Details

I. General information

NPI: 1194270413
Provider Name (Legal Business Name): ST MARYS INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ESSEX CENTER DR SUITE 304
PEABODY MA
01960-2904
US

IV. Provider business mailing address

6 ESSEX CENTER DR SUITE 304
PEABODY MA
01960-2904
US

V. Phone/Fax

Practice location:
  • Phone: 978-854-6376
  • Fax:
Mailing address:
  • Phone: 978-854-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number236055
License Number StateMA

VIII. Authorized Official

Name: DR. SUNGSIK HAHN
Title or Position: PRESIDENT
Credential: MD
Phone: 508-265-3975