Basic Information
| Provider Information | |||||||||
| NPI: | 1609007806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAE Y HONG M D A PROFESSIONAL CORPORATION | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2858 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935392858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617296854 | ||||||||
| FaxNumber: | 6617296864 | ||||||||
| Practice Location | |||||||||
| Address1: | 44301 LORIMER AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619401112 | ||||||||
| FaxNumber: | 6617236402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | HONG | ||||||||
| AuthorizedOfficialFirstName: | JAE | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | ANESTHESIOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 6617296854 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A31851 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00A318510 | 05 | CA | MEDICAID | AH1074309 | 01 | CA | DEA | OTHER | 00A318510 | 01 | CA | BLUE SHIELD | OTHER | 050066604 | 01 | CA | MEDICARE RAILROAD | OTHER |