Basic Information
| Provider Information | |||||||||
| NPI: | 1104059708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HWANG | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1721 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 S STEPHENSON AVE | ||||||||
| Address2: | STE 115 | ||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765970 | ||||||||
| FaxNumber: | 9062280215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2009 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101018418 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 295621 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0053917 | 01 | CO | MEDICAL | OTHER | 5101018418 | 01 | MI | LICENSE | OTHER |