MEDICARE: DR. SUNG GOHN PARK 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	207L00000X	Anesthesiology Physician	0101030177	VA

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

General Provider Information

NPI Number	:	1841245180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUNG GOHN PARK M.D.

Provider Business Mailing Address
First Line	:	DEPT 1041 PO BOX 740209
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-0209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2621 GROVE AVENUE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-4300
Country	:	US
Telephone Number	:	804-254-5100
Fax Number	:

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

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	05/05/2009

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