Basic Information
| Provider Information | |||||||||
| NPI: | 1679541619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHN | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | KYUNG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4355 169TH ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113583246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184454974 | ||||||||
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| Practice Location | |||||||||
| Address1: | ST. BARNABAS HOSPITAL | ||||||||
| Address2: | 183RD STREET AND THIRD AVE. | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609000 | ||||||||
| FaxNumber: | 7189606125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 218496 | NY | X | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 218496 | NY | X | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02195182 | 05 | NY | MEDICAID |