Basic Information
| Provider Information | |||||||||
| NPI: | 1669451738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | KEON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S MERRIMAN RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481865544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347293133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301037628 | MI | N | Other Service Providers | Specialist | 2084P0800X | 037628 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2884620 10 | 05 | MI | MEDICAID |