MEDICARE: DR. KAITLIN PARK D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program	5101021070	MI
2	208000000X	Pediatrics Physician	5101021070	MI

General Provider Information

NPI Number	:	1255745634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAITLIN PARK D.O.

Provider Business Mailing Address
First Line	:	75 BARCLAY CIR STE 115
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5803
Country	:	US
Telephone Number	:	248-856-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 BARCLAY CIR STE 115
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5803
Country	:	US
Telephone Number	:	248-856-6300
Fax Number	:

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

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	03/16/2020

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