Basic Information
| Provider Information | |||||||||
| NPI: | 1720063100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIANG | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | SYRU | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3294 NORTH OAK STREET EXT | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Practice Location | |||||||||
| Address1: | 3294 NORTH OAK STREET EXT. | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 03/09/2012 | ||||||||
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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 | 208800000X | 018627 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340005901 | 01 | GA | MEDICARE RAILROAD | OTHER | 000244791B | 05 | GA | MEDICAID |