Healthcare Provider Details

I. General information

NPI: 1568423986
Provider Name (Legal Business Name): JOE S CHOMCHAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 E PICKARD ST STE 2700
MOUNT PLEASANT MI
48858-2042
US

IV. Provider business mailing address

4851 E PICKARD ST STE 2700
MOUNT PLEASANT MI
48858-2042
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-6848
  • Fax: 989-317-9263
Mailing address:
  • Phone: 989-772-6848
  • Fax: 989-317-9263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number4301063374
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number4301063374
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: