Basic Information
| Provider Information | |||||||||
| NPI: | 1063702702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | HWAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2011 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 25MA10273100 | NJ | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD460767 | PA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 103349031 | 05 | PA | MEDICAID | 674133 | 05 | NJ | MEDICAID |