Basic Information
Provider Information | |||||||||
NPI: | 1356568745 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | C. J. YOON, M.D., PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REHABILITATION MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 833 W LINCOLN HWY | ||||||||
Address2: | SUITE 200W | ||||||||
City: | SCHERERVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 463751683 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199345300 | ||||||||
FaxNumber: | 2199345389 | ||||||||
Practice Location | |||||||||
Address1: | 8701 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | MERRILLVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 464107035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2197385775 | ||||||||
FaxNumber: | 2197365856 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 12/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOON | ||||||||
AuthorizedOfficialFirstName: | C.J. | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2197385775 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D., P.C. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 100340330 | 05 | IN |   | MEDICAID |