Provider Demographics
NPI:1336110113
Name:CHUNG, KI YOUNG (MD)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:YOUNG
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:120 DILLON DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1018
Practice Address - Country:US
Practice Address - Phone:864-699-5700
Practice Address - Fax:864-699-5701
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33366207RH0003X
NY213762207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC333669Medicaid
SC1336110113Medicaid
SC333669Medicaid
SCAA66547951Medicare PIN