Basic Information
Provider Information | |||||||||
NPI: | 1487612974 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KO | ||||||||
FirstName: | CARLYN | ||||||||
MiddleName: | YEONG SOOK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454295164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008750136 | ||||||||
FaxNumber: | 9376194231 | ||||||||
Practice Location | |||||||||
Address1: | 630 EATON AVE | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 450132767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138672270 | ||||||||
FaxNumber: | 5138672581 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 05/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35083978K | OH | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00290024 | 01 | OH | MEDICARE RAIL ROAD | OTHER | P00105509 | 01 |   | RAIL ROAD MEDICARE | OTHER | 2484566 | 05 | OH |   | MEDICAID | 000000372342 | 01 | OH | ANTHEM/BCBS | OTHER | 000000326463 | 01 | OH | BCBS | OTHER |