Healthcare Provider Details

I. General information

NPI: 1548255318
Provider Name (Legal Business Name): TAE KAE CHONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 N LEBANON ST STE 315
LEBANON IN
46052-8622
US

IV. Provider business mailing address

2605 N LEBANON ST
LEBANON IN
46052-1476
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-8855
  • Fax: 765-485-8850
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01039705A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01039705A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: