Healthcare Provider Details

I. General information

NPI: 1669451738
Provider Name (Legal Business Name): KEON CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MERRIMAN RD
WESTLAND MI
48186-5544
US

IV. Provider business mailing address

5623 E DUNBAR RD
MONROE MI
48161-9127
US

V. Phone/Fax

Practice location:
  • Phone: 734-729-3133
  • Fax:
Mailing address:
  • Phone: 734-241-3891
  • Fax: 734-241-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301037628
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number037628
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: