Healthcare Provider Details

I. General information

NPI: 1215996665
Provider Name (Legal Business Name): CHUNG-HO CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST CHILDREN'S HOSPITAL OF MI PATHOLOGY
DETROIT MI
48201-2119
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-2553
  • Fax: 313-993-8754
Mailing address:
  • Phone: 248-581-5974
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301031363
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: