Provider Demographics
NPI:1174510804
Name:CHUNG, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-7080
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:3333 SILAS CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-7080
Practice Address - Fax:336-718-9622
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100662207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132F2Medicaid
SCN00663Medicaid
NC1174510804OtherRAILROAD MEDICARE
NC132F2OtherBLUECROSS BLUESHIELD
NC1174510804OtherBLUE MEDICARE
NC110238891OtherRAILROAD MEDICARE
NC2299826BMedicare PIN
SCN00663Medicaid
NC89132F2Medicaid