MEDICARE: SOOMCHUNGMDONCOLOGY-HEMATOLOGYPC

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	207R00000X	Internal Medicine Physician	A41090	CA
2	207RH0003X	Hematology & Oncology Physician	A41090	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	05D0675453	OTHER	CA	CLIA

General Provider Information

NPI Number	:	1386812394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOOMCHUNGMDONCOLOGY-HEMATOLOGYPC

Provider Business Mailing Address
First Line	:	12555 GARDEN GROVE BLVD STE 309
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1903
Country	:	US
Telephone Number	:	714-539-6414
Fax Number	:	714-539-6933

Provider Business Practice Location Address
First Line	:	12555 GARDEN GROVE BLVD STE 309
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1903
Country	:	US
Telephone Number	:	714-539-6414
Fax Number	:	714-539-6933

Authorized Official
Title or Position	:	CEO
Name	:	SOO MARN CHUNG
Credential	:	M.D.
Telephone Number	:	714-539-6414

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	02/12/2008

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