Healthcare Provider Details

I. General information

NPI: 1467412593
Provider Name (Legal Business Name): CHANG HWAN BAHNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: CHANG HWAN BANG M.D.

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MICHIGAN ST
SIDNEY OH
45365-2401
US

IV. Provider business mailing address

PO BOX 5128
LIMA OH
45802-5128
US

V. Phone/Fax

Practice location:
  • Phone: 937-498-2311
  • Fax:
Mailing address:
  • Phone: 419-224-5707
  • Fax: 419-229-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.041023
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: