Basic Information
| Provider Information | |||||||||
| NPI: | 1619940681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | CHAN | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5508 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234710508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Practice Location | |||||||||
| Address1: | MICHUMI, PLLC DBA MED EXPRESS OF WILLIAMSBURG, VA | ||||||||
| Address2: | 120 MONTICELLO AVE | ||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575643627 | ||||||||
| FaxNumber: | 7575646449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101043881 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010094321 | 05 | VA | MEDICAID | P00153223 | 01 | VA | RRMED | OTHER |