Provider Demographics
NPI:1245398270
Name:KENNETH S CHANG MD PA
Entity Type:Organization
Organization Name:KENNETH S CHANG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-792-9339
Mailing Address - Street 1:3144 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:201-792-9339
Mailing Address - Fax:201-792-9818
Practice Address - Street 1:3144 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-792-9339
Practice Address - Fax:201-792-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA38097207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ118400150336Medicaid
00484242Medicare ID - Type Unspecified
NJ118400150336Medicaid