=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962625160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNG J PAHNG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 11/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21704 NORTHERN BLVD STE 2
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-353-6835
-----------------------------------------------------
Fax | 718-353-6854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21704 NORTHERN BLVD STE 2
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-353-6835
-----------------------------------------------------
Fax | 718-353-6854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number | 188371
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------