Provider Demographics
NPI:1629305685
Name:HYUN S CHANG M D P C
Entity Type:Organization
Organization Name:HYUN S CHANG M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-6999
Mailing Address - Street 1:3815 PELHAM ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3852
Mailing Address - Country:US
Mailing Address - Phone:313-565-6999
Mailing Address - Fax:313-565-8754
Practice Address - Street 1:3815 PELHAM ST
Practice Address - Street 2:SUITE 5
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3852
Practice Address - Country:US
Practice Address - Phone:313-565-6999
Practice Address - Fax:313-565-8754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035471208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2713276Medicaid
MI020052557OtherPALMETTO GBA
MI020052557OtherPALMETTO GBA
0821008Medicare PIN