Basic Information
| Provider Information | |||||||||
| NPI: | 1700895885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | KONG | ||||||||
| MiddleName: | YOUNG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 578 N LEAVITT RD | ||||||||
| Address2: | C/O MMS | ||||||||
| City: | AMHERST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440011131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409881009 | ||||||||
| FaxNumber: | 4409881225 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409604000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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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 | 2084P0800X | 35.037196 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2689863 | 05 | OH | MEDICAID | 2943917 | 05 | OH | MEDICAID |