Basic Information
| Provider Information | |||||||||
| NPI: | 1629071840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUTHRIE DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148303696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6079737200 | ||||||||
| FaxNumber: | 6079377866 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GUTHRIE DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148303696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6079737200 | ||||||||
| FaxNumber: | 6079377866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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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 | 174400000X | 25MA07546600 | NJ | N | Other Service Providers | Specialist | 207L00000X | 2348/23 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0040886 | 05 | NJ | MEDICAID |