Basic Information
| Provider Information | |||||||||
| NPI: | 1356784441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | E-KONG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 EATON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450132716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138671200 | ||||||||
| FaxNumber: | 5138671266 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 EATON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450132716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138671200 | ||||||||
| FaxNumber: | 5138671266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 51355 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 35.137264 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0325648 | 05 | OH | MEDICAID |