MEDICARE: DR. JONGDAE SUH 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	390200000X	Student in an Organized Health Care Education/Training Program
2	2085N0904X	Nuclear Radiology Physician	A103753	CA

General Provider Information

NPI Number	:	1881891182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONGDAE SUH M.D.

Provider Business Mailing Address
First Line	:	3827 PAXTON AVE.
Second Line	:	838
City	:	CINCINNATI
State	:	OH
Zip	:	45209
Country	:	US
Telephone Number	:	714-676-4887
Fax Number	:

Provider Business Practice Location Address
First Line	:	3827 PAXTON AVE.
Second Line	:	838
City	:	CINCINNATI
State	:	OH
Zip	:	45209
Country	:	US
Telephone Number	:	714-676-4887
Fax Number	:

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

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/17/2011

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