Basic Information
Provider Information | |||||||||
NPI: | 1386721470 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAK | ||||||||
FirstName: | CHIN HO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PAK | ||||||||
OtherFirstName: | THOMAS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 284 EXECUTIVE PARK DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280251833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049391100 | ||||||||
FaxNumber: | 7049391173 | ||||||||
Practice Location | |||||||||
Address1: | 1190 W ROOSEVELT BLVD | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | NC | ||||||||
PostalCode: | 281102818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042966200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 10/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 200300514 | NC | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 2084P0800X | 05 | NC |   | MEDICAID | 891335T | 05 | NC |   | MEDICAID |