Basic Information
| Provider Information | |||||||||
| NPI: | 1194713131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUH | ||||||||
| FirstName: | YOO | ||||||||
| MiddleName: | TAIK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N RACE ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706514444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 N L ROGERS WELLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706593398 | ||||||||
| FaxNumber: | 2706511892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME132993 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 2021-02420 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 39503 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 000000371086 | 01 | KY | BCBS | OTHER | 64103005 | 05 | KY | MEDICAID |