Provider Demographics
NPI:1316079452
Name:MONGKOL MONG, M.D.P.C.
Entity type:Organization
Organization Name:MONGKOL MONG, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONGKOL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGKOLPRADIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-285-2255
Mailing Address - Street 1:15332 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1304
Mailing Address - Country:US
Mailing Address - Phone:734-285-2255
Mailing Address - Fax:734-285-9044
Practice Address - Street 1:15332 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1304
Practice Address - Country:US
Practice Address - Phone:734-285-2255
Practice Address - Fax:734-285-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM032063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1421722Medicaid
MI0828033OtherBLUE CROSS BLUE SHIELD
MIMM032063OtherMEDICAL LICENSE
MI0828033OtherBLUE CROSS BLUE SHIELD
MIMM032063OtherMEDICAL LICENSE
MIB45032Medicare UPIN
MI0828033Medicare ID - Type Unspecified