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General NPI Number Information
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NPI Number | 1104865849
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Entity Type | Organization
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Legal Business Name | CHAN PARK MD INC
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 905 VICTORY HIGHWAY
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City | SLATERSVILLE
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State | RI
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Zip | 02876
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Country | US
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Telephone | 401-762-2728
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Fax | 401-762-0473
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Provider Business Mailing Address
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Address Line | PO BOX 177 905 VICTORY HWY
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City | SLATERSVILLE
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State | RI
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Zip | 02876
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Country | US
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Telephone | 401-762-2728
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Fax | 401-762-0473
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Authorized Official
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Title or Position | OWNER
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Name | CHAN HOON PARK
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Credential | MD
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Telephone | 401-762-2728
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD5083
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License Number State | RI
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