Basic Information
Provider Information | |||||||||
NPI: | 1215996665 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHANG | ||||||||
FirstName: | CHUNG-HO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1420 STEPHENSON HWY | ||||||||
Address2: | SUITE 400-CREDENTIALING | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480831189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485815974 | ||||||||
FaxNumber: | 2485815640 | ||||||||
Practice Location | |||||||||
Address1: | 3901 BEAUBIEN ST | ||||||||
Address2: | CHILDREN'S HOSPITAL OF MI PATHOLOGY | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137452553 | ||||||||
FaxNumber: | 3139938754 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2006 | ||||||||
LastUpdateDate: | 01/15/2014 | ||||||||
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 | 207ZP0102X | 4301031363 | MI | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 2785758 | 05 | MI |   | MEDICAID | 220F362370 | 01 | MI | BCBSM | OTHER |