MEDICARE: DR. WALLEN CY CHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	183203	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043287857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLEN CY CHAN M.D.

Provider Business Mailing Address
First Line	:	4 AIRDALE DR
Second Line	:
City	:	KENDALL PARK
State	:	NJ
Zip	:	08824-1494
Country	:	US
Telephone Number	:	718-448-1122
Fax Number	:	718-448-8318

Provider Business Practice Location Address
First Line	:	78 TODT HILL RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-4528
Country	:	US
Telephone Number	:	718-448-1122
Fax Number	:	718-448-8318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	04/14/2008

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