Provider Demographics
NPI:1194760157
Name:CHANG, CHUL (MD)
Entity type:Individual
Prefix:DR
First Name:CHUL
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-8531
Mailing Address - Country:US
Mailing Address - Phone:269-463-6900
Mailing Address - Fax:269-463-6900
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-463-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC043583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M55810OtherMEDICARE - BANGOR
MI2589390Medicaid
MI3208317Medicaid
MI1101102151OtherBLUECROSSBLUESHIELDOFMI
MI110H010030OtherBCBSM - BANGOR
MI110H010030OtherBCBSM - BANGOR
MI1101102151OtherBLUECROSSBLUESHIELDOFMI