MEDICARE: MICHAEL 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	207K00000X	Allergy & Immunology Physician	4301063179	MI

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	:	1942204680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL PARK M.D.

Provider Business Mailing Address
First Line	:	430 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5304
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:	269-324-5594

Provider Business Practice Location Address
First Line	:	430 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5304
Country	:	US
Telephone Number	:	269-321-6673
Fax Number	:	269-324-5594

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	07/16/2007

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Directions to “ MICHAEL PARK M.D.” Practice Location

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