Healthcare Provider Details

I. General information

NPI: 1790467660
Provider Name (Legal Business Name): BYUNG SOO KEUM MSN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 KIRTS BLVD APT 70
TROY MI
48084-5267
US

IV. Provider business mailing address

481 KIRTS BLVD APT 70
TROY MI
48084-5267
US

V. Phone/Fax

Practice location:
  • Phone: 248-686-4586
  • Fax:
Mailing address:
  • Phone: 248-686-4586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number470433097
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: