1760472401 NPI number — DR. CHARLES CHANSIK HONG MD PHD

Table of content: DR. CHARLES CHANSIK HONG MD PHD (NPI 1760472401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760472401 NPI number — DR. CHARLES CHANSIK HONG MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HONG
Provider First Name:
CHARLES
Provider Middle Name:
CHANSIK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760472401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD STE A202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-353-4911
Provider Business Mailing Address Fax Number:
517-432-3928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4650 S HAGADORN RD STE 600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-5396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-267-2460
Provider Business Practice Location Address Fax Number:
517-267-2462
Provider Enumeration Date:
10/25/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD41638 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 4301510421 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2070651 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 464483 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J27281 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".