Provider Demographics
NPI:1144394859
Name:CHUNG, HACK R (MD)
Entity Type:Individual
Prefix:
First Name:HACK
Middle Name:R
Last Name:CHUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WILLOW AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3100
Mailing Address - Country:US
Mailing Address - Phone:732-447-3264
Mailing Address - Fax:215-653-7872
Practice Address - Street 1:1400 WILLOW AVE STE B1
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-3100
Practice Address - Country:US
Practice Address - Phone:732-447-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032058L208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012229190010Medicaid
PA62158701Medicaid
C28701Medicare UPIN