=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124327614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WON CHAE M D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2011
-----------------------------------------------------
Last Update Date | 05/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 W HURON ST
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-857-7515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1108 ATTN: BARB SIMMONS
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48106-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-7400
-----------------------------------------------------
Fax | 734-677-7407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WON B CHAE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 734-677-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------