Healthcare Provider Details

I. General information

NPI: 1396741864
Provider Name (Legal Business Name): PAULINO Y. CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MACARTHUR BLVD STE 21
MUNSTER IN
46321-2918
US

IV. Provider business mailing address

800 MACARTHUR BLVD STE 21
MUNSTER IN
46321-2918
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1163
  • Fax: 219-836-0588
Mailing address:
  • Phone: 219-836-1163
  • Fax: 219-836-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number027974
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: