Provider Demographics
NPI:1124327614
Name:WON CHAE M D P C
Entity type:Organization
Organization Name:WON CHAE M D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WON
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-677-7400
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTN: BARB SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F39535OtherBCBS GROUP
MI0F39535OtherBCBS GROUP