Basic Information
| Provider Information | |||||||||
| NPI: | 1043684517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEONG | ||||||||
| FirstName: | SEONGHUN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21502 46TH AVE | ||||||||
| Address2: | FL 2 | ||||||||
| City: | BAYSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113613437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133098179 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1283 W DUNDEE RD | ||||||||
| Address2: | |||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600894009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476329919 | ||||||||
| FaxNumber: | 7735856201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2015 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 045412 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070021866 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.