Healthcare Provider Details

I. General information

NPI: 1508219940
Provider Name (Legal Business Name): KONCHOK NORGAIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD RM A225
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

788 SERVICE RD RM B301
EAST LANSING MI
48824-7013
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-4941
  • Fax: 517-432-3145
Mailing address:
  • Phone: 517-353-5100
  • Fax: 517-432-2759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301110637
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: