Basic Information
| Provider Information | |||||||||
| NPI: | 1356322697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2535 ARTHUR KILL RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103091207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184483210 | ||||||||
| FaxNumber: | 7189676023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1099 TARGEE ST | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103044310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184483210 | ||||||||
| FaxNumber: | 7188153379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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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 | 207T00000X | 1752211 | NY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | MA52820 | NJ | N | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01512041 | 05 | NY | MEDICAID | 130016692 | 01 | NY | RAILROAD MEDICARE | OTHER |