1811091085 NPI number — EUN CHUNG D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811091085 NPI number — EUN CHUNG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHUNG
Provider First Name:
EUN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHUNG
Provider Other First Name:
CONNIE
Provider Other Middle Name:
KYUNG
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811091085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT ROAD, NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7070
Provider Business Mailing Address Fax Number:
228-865-1457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2470 MT. ZION PARKWAY
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE SOUTHWOOD SPECIALTY CENTER
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-868-9641
Provider Business Practice Location Address Fax Number:
228-867-4855
Provider Enumeration Date:
09/11/2006

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: 207R00000X , with the licence number:  2005013743 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 19730 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 064912 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07532826 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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