MEDICARE: DR. KI SOO HWANG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	240401	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	240401	OTHER	NY	NYS MEDICAL LICENSE
2	25MA08144900	OTHER	NJ	NJ STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1205846680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KI SOO HWANG M.D.

Provider Business Mailing Address
First Line	:	504 VALLEY RD
Second Line	:	2ND FLOOR
City	:	WAYNE
State	:	NJ
Zip	:	07470-3534
Country	:	US
Telephone Number	:	973-686-0700
Fax Number	:	973-686-0701

Provider Business Practice Location Address
First Line	:	504 VALLEY RD
Second Line	:	2ND FLOOR
City	:	WAYNE
State	:	NJ
Zip	:	07470-3534
Country	:	US
Telephone Number	:	973-686-0700
Fax Number	:	973-686-0701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	09/18/2015

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