Basic Information
| Provider Information | |||||||||
| NPI: | 1922528504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 REID PARKWAY, SUITE 300 | ||||||||
| Address2: | REID HOSPITAL FAMILY MEDICINE RESIDENCY | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659669549 | ||||||||
| FaxNumber: | 7659626268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2017 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11019403A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 34.014241 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0408209 | 05 | OH | MEDICAID |