Provider Demographics
NPI:1083780266
Name:PHYLLIS CHANG, M.D., PLC
Entity Type:Organization
Organization Name:PHYLLIS CHANG, M.D., PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-358-8788
Mailing Address - Street 1:604 5TH ST
Mailing Address - Street 2:PO BOX 5036
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2304
Mailing Address - Country:US
Mailing Address - Phone:319-358-8788
Mailing Address - Fax:319-351-9278
Practice Address - Street 1:604 5TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2304
Practice Address - Country:US
Practice Address - Phone:319-358-8788
Practice Address - Fax:319-351-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA269972082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0450049Medicaid
IA0450049Medicaid