Healthcare Provider Details

I. General information

NPI: 1730286055
Provider Name (Legal Business Name): EDWARD KWANGHYOUN CHUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 OLD ROAD TO NINE ACRE CORNER
CONCORD MA
01742
US

IV. Provider business mailing address

133 OLD ROAD TO NINE ACRE CORNER
CONCORD MA
01742
US

V. Phone/Fax

Practice location:
  • Phone: 978-369-1400
  • Fax:
Mailing address:
  • Phone: 978-369-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number229984
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18411
License Number StateNH

VII. Legacy identifiers

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

# 1
Identifier3112730
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: