Basic Information
Provider Information | |||||||||
NPI: | 1346687019 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEONG | ||||||||
FirstName: | SEON MI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 W 246TH ST | ||||||||
Address2: | APT 216 | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104713611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2677885074 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 34TH STREET AND CIVIC CENTER BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155903083 | ||||||||
FaxNumber: | 2674264099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2013 | ||||||||
LastUpdateDate: | 12/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | SP012857 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0005X | AP60320126 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0005X | F350353-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.