=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881630341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANSUK CHAE MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7445 ALLEN RD SUITE 180
-----------------------------------------------------
City | ALLEN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48101-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-383-4833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7445 ALLEN RD SUITE 180
-----------------------------------------------------
City | ALLEN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48101-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-383-4833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING AGENT/OWNER
-----------------------------------------------------
Name | MANSUK CHAE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 313-383-4833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 4301032356
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------