Provider Demographics
NPI:1639165947
Name:CHUNG, PHILLIP YUNMOGEE (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:YUNMOGEE
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 1:6308 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-653-5330
Mailing Address - Fax:262-653-5346
Practice Address - Street 1:6308 8TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-653-5330
Practice Address - Fax:262-653-5346
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2018-07-20
Deactivation Date:2018-06-19
Deactivation Code:
Reactivation Date:2018-07-03
Provider Licenses
StateLicense IDTaxonomies
WI45462207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34359700Medicaid
WI1639165947Medicaid
WI34359700Medicaid