Healthcare Provider Details

I. General information

NPI: 1902809601
Provider Name (Legal Business Name): TAE'NI CHANG-STROMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 JOLIET ST STE 103
DYER IN
46311-1925
US

IV. Provider business mailing address

1160 JOLIET ST STE 103
DYER IN
46311-1925
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-8534
  • Fax: 219-865-9072
Mailing address:
  • Phone: 219-322-8534
  • Fax: 219-865-9072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01042969
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier90001231
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBSIL PROVIDER ID
# 2
Identifier000000365599
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM PROVIDER ID
# 3
Identifier100463430B
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 4
Identifier10780906
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: