=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528359320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMBA JUNG M D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2011
-----------------------------------------------------
Last Update Date | 05/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1724 AIRPORT RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48327-1390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-674-1220
-----------------------------------------------------
Fax | 248-674-1398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1724 AIRPORT RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48327-1390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-674-1220
-----------------------------------------------------
Fax | 248-674-1398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | SAMBA JUNG
-----------------------------------------------------
Credential | M D
-----------------------------------------------------
Telephone | 248-674-1220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 032194
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------