Provider Demographics
NPI:1376729426
Name:DOCTOR CHAN MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:DOCTOR CHAN MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-406-2301
Mailing Address - Street 1:202 CANAL ST STE 801
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4517
Mailing Address - Country:US
Mailing Address - Phone:212-406-2301
Mailing Address - Fax:212-406-2359
Practice Address - Street 1:202 CANAL ST STE 801
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4517
Practice Address - Country:US
Practice Address - Phone:212-406-2301
Practice Address - Fax:212-406-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193850207R00000X, 246XC2901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XC2901XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularCardiovascular Invasive SpecialistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617692Medicaid
NY01617692Medicaid
NY=========OtherTAX ID
013381Medicare PIN