Basic Information
| Provider Information | |||||||||
| NPI: | 1982661823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168592954 | ||||||||
| FaxNumber: | 7168592962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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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 | 2085R0202X | 9600886 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 234701 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00027018504 | 01 | UNIVERA | OTHER | 000528052001 | 01 | NY | BLUE SHIELD WNY | OTHER | 000528052007 | 01 | BLUE SHIELD WNY | OTHER | 050922000000 | 01 | FIDELIS | OTHER | 196562FF | 01 | PREFERRED CARE | OTHER | P010234701 | 01 | BLUE CHOICE | OTHER | 00027018501 | 01 | UNIVERA | OTHER | 1612812 | 01 | INDEPENDENT HEALTH | OTHER | P00232918 | 01 | RR MEDICARE | OTHER | 2347011W | 01 | NY | NYS WORKERS COMPENSATION | OTHER | 4193544 | 01 | GHI | OTHER | 0142853 | 01 | GHI | OTHER | 01756523 | 05 | NY | MEDICAID | P00193057 | 01 | RR MEDICARE | OTHER | P020234701 | 01 | BLUE SHIELD OF ROCHESTER | OTHER |