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General NPI Number Information
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NPI Number | 1053579912
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Entity Type | Organization
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Legal Business Name | MARK K CHANG MD
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 01/12/2015
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Provider Practice Location Address
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Address Line | 1100 JOLIET ST SUITE 104
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City | DYER
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State | IN
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Zip | 46311-1996
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Country | US
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Telephone | 219-836-4955
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 JOLIET ST SUITE 104
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City | DYER
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State | IN
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Zip | 46311-1996
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Country | US
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Telephone | 219-836-4955
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MARK K CHANG
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Credential | MD
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Telephone | 219-836-4955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0117X
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Taxonomy Name | Orthopaedic Surgery of the Spine Physician
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License Number | 036095817
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License Number State | IL
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