Provider Demographics
NPI:1225158868
Name:BOONCHOO CHANG M.D., P.C.
Entity Type:Organization
Organization Name:BOONCHOO CHANG M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOONCHOO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-782-7150
Mailing Address - Street 1:417 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-1906
Mailing Address - Country:US
Mailing Address - Phone:269-782-7150
Mailing Address - Fax:269-782-7020
Practice Address - Street 1:417 W HIGH ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1906
Practice Address - Country:US
Practice Address - Phone:269-782-7150
Practice Address - Fax:269-782-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBC031400261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093701Medicaid
MI0141181Medicare ID - Type UnspecifiedMEDICARE
MI23-3905Medicare ID - Type UnspecifiedRURAL HEALTH MEDICARE
MI1093701Medicaid