=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194760157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHUL CHANG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 11/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 MEDICAL PARK DR
-----------------------------------------------------
City | WATERVLIET
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49098-9225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-463-2449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 MEDICAL PARK DR
-----------------------------------------------------
City | WATERVLIET
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49098-8531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-463-6900
-----------------------------------------------------
Fax | 269-463-6900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | CC043583
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------