Provider Demographics
NPI:1417137365
Name:PARK, CHANDLER H (MD, MSC)
Entity type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1263 HOSPITAL DR NW STE 110
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2173
Practice Address - Country:US
Practice Address - Phone:812-734-0912
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48923207RH0003X
WV25614390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01150420OtherRAILROAD MEDICARE
OH57.013780OtherCREDENTIAL NUMBER
IN201083260Medicaid
INP01150420OtherRAILROAD MEDICARE