Provider Demographics
NPI:1912255746
Name:MOON PAIK MD
Entity type:Organization
Organization Name:MOON PAIK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-226-3671
Mailing Address - Street 1:28111 HOOVER RD
Mailing Address - Street 2:UNIT 7A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4153
Mailing Address - Country:US
Mailing Address - Phone:586-573-0902
Mailing Address - Fax:
Practice Address - Street 1:28111 HOOVER RD
Practice Address - Street 2:UNIT 7A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4153
Practice Address - Country:US
Practice Address - Phone:586-573-0902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033213207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4784698Medicaid
MI4784698Medicaid