Provider Demographics
NPI:1003022476
Name:MARK K CHANG MD
Entity Type:Organization
Organization Name:MARK K CHANG MD
Other - Org Name:MIDWEST SPINECARE, SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-4955
Mailing Address - Street 1:1100 JOLIET ST
Mailing Address - Street 2:STE 104
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1996
Mailing Address - Country:US
Mailing Address - Phone:219-836-4955
Mailing Address - Fax:219-865-2377
Practice Address - Street 1:1100 JOLIET ST
Practice Address - Street 2:STE 104
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1996
Practice Address - Country:US
Practice Address - Phone:219-836-4955
Practice Address - Fax:219-865-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095817207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200868870AMedicaid
ILDG1633OtherRR MEDICARE
IN200868870AMedicaid
ININ2023Medicare Oscar/Certification
IN251090Medicare PIN
IN5930340002Medicare NSC
G45938Medicare UPIN