MEDICARE: ELLEN CHANG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374K00000X	Religious Nonmedical Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NONE

General Provider Information

NPI Number	:	1841761582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN CHANG

Provider Business Mailing Address
First Line	:	1601 3RD AVE APT 20B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-3456
Country	:	US
Telephone Number	:	917-747-0011
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 3RD AVE APT 20B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-3456
Country	:	US
Telephone Number	:	917-747-0011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2018
Last Update Date	:	12/06/2018

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Directions to “ ELLEN CHANG ” Practice Location

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