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General NPI Number Information
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NPI Number | 1821304288
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Entity Type | Organization
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Legal Business Name | PARK OB GYN
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Dates
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Enumeration Date | 08/24/2010
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Last Update Date | 02/17/2011
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Provider Practice Location Address
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Address Line | 16570 19 MILE RD
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City | CLINTON TWP
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State | MI
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Zip | 48038-1106
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Country | US
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Telephone | 586-263-7660
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Fax | 586-263-4727
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Provider Business Mailing Address
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Address Line | 16570 19 MILE RD
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City | CLINTON TWP
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State | MI
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Zip | 48038-1106
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Country | US
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Telephone | 586-263-7660
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Fax | 586-263-4727
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Authorized Official
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Title or Position | PHYSICIAN PRESIDENT
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Name | CHANKEE PARK
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Credential | MD
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Telephone | 586-263-7660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 4301037049
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License Number State | MI
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