Provider Demographics
NPI:1649631813
Name:S PARK-DAVIS HEALTHCARE
Entity type:Organization
Organization Name:S PARK-DAVIS HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNGNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-229-0640
Mailing Address - Street 1:30880 BECK RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1000
Mailing Address - Country:US
Mailing Address - Phone:248-926-0009
Mailing Address - Fax:248-926-8972
Practice Address - Street 1:30880 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1000
Practice Address - Country:US
Practice Address - Phone:248-926-0009
Practice Address - Fax:248-926-8972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN89750003Medicare PIN