Provider Demographics
NPI:1073787941
Name:KWANG P CHUNG MD SC
Entity Type:Organization
Organization Name:KWANG P CHUNG MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KWANG
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-246-6344
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:903 GREENBRIER RD
Mailing Address - City:EARLVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60518-0607
Mailing Address - Country:US
Mailing Address - Phone:815-246-6344
Mailing Address - Fax:815-246-4711
Practice Address - Street 1:903 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:IL
Practice Address - Zip Code:60518-0607
Practice Address - Country:US
Practice Address - Phone:815-246-6344
Practice Address - Fax:815-246-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055582208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055582Medicaid
IL036055582Medicaid
D09780Medicare UPIN