MEDICARE: HAE YOON KWON P.T.

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	225100000X	Physical Therapist	PTH3962	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051513721KWO	OTHER	AL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1487703310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAE YOON KWON P.T.

Provider Business Mailing Address
First Line	:	2953 PELHAM PKWY
Second Line	:
City	:	PELHAM
State	:	AL
Zip	:	35124-1708
Country	:	US
Telephone Number	:	205-624-2436
Fax Number	:	205-624-2439

Provider Business Practice Location Address
First Line	:	1310 ALFORD AVE
Second Line	:	SUITE 102
City	:	HOOVER
State	:	AL
Zip	:	35226-3199
Country	:	US
Telephone Number	:	205-824-8850
Fax Number	:	205-824-8853

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	06/21/2022

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Directions to “ HAE YOON KWON P.T.” Practice Location

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