Provider Demographics
NPI:1316998792
Name:BAE, HAN-SOO (MD)
Entity type:Individual
Prefix:DR
First Name:HAN-SOO
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4393
Mailing Address - Country:US
Mailing Address - Phone:734-243-5020
Mailing Address - Fax:734-457-1970
Practice Address - Street 1:321 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4393
Practice Address - Country:US
Practice Address - Phone:734-243-5020
Practice Address - Fax:734-457-1970
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075954207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4568755Medicaid
N84640002OtherPECOS
MI0405810152OtherBLUE SHIELD
MI4568755Medicaid
MII36730Medicare UPIN