Healthcare Provider Details

I. General information

NPI: 1508209248
Provider Name (Legal Business Name): ELLEN CHANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE., ML 7018
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE., ML 7018
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-517-2234
  • Fax: 513-636-3549
Mailing address:
  • Phone: 513-517-2234
  • Fax: 513-636-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA148550
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number35.143074
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: