Basic Information
| Provider Information | |||||||||
| NPI: | 1326533019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | CHUL WON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | W3985 COUNTY ROAD NN | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531214337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627412000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 252 MCHENRY ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531051828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627676000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 74782-20 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 74782 | WI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 100165130 | 05 | WI | MEDICAID |