Basic Information
| Provider Information | |||||||||
| NPI: | 1215377742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAEK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SEUNGJUN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 OPITZ BLVD STE G-209 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035230611 | ||||||||
| FaxNumber: | 7036702089 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 OPITZ BLVD STE G-209 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035230611 | ||||||||
| FaxNumber: | 7036702089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101260492 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 0116026404 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 0101260492 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 207Q00000X | 01 | VA | FAMILY MEDICINE | OTHER |