Basic Information
Provider Information | |||||||||
NPI: | 1144244344 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHANG | ||||||||
FirstName: | PHILEMON | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2715 ANDERSON RD | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372174001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6157469533 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 161 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | MC KENZIE | ||||||||
State: | TN | ||||||||
PostalCode: | 382011636 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7313525344 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 12/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 17803 | TN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207R00000X | 17803 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1507231 | 05 | TN |   | MEDICAID | P00643326 | 01 | TN | RAILROAD MEDICARE | OTHER | 3883884 | 05 | TN |   | MEDICAID | 4192397 | 01 | TN | BCBS | OTHER |