1053579912 NPI number — MARK K CHANG MD

Table of content: (NPI 1053579912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053579912 NPI number — MARK K CHANG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK K CHANG MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1053579912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 JOLIET ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
DYER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46311-1996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-4955
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 JOLIET ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
DYER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46311-1996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-4955
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
MARK
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
219-836-4955

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  036095817 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03609507 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5930340001 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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