Basic Information
| Provider Information | |||||||||
| NPI: | 1114900826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | B.K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043165100 | ||||||||
| FaxNumber: | 7043165101 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S HERLONG AVE STE B | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033241950 | ||||||||
| FaxNumber: | 8033241933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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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 | 208G00000X | 9600879 | NC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 28435 | SC | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | N00879 | 05 | SC | MEDICAID | 8921992 | 05 | NC | MEDICAID |