Provider Demographics
NPI:1710549779
Name:CENTERHEALTH MEDICAL PLLC
Entity Type:Organization
Organization Name:CENTERHEALTH MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WAN TAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-578-1318
Mailing Address - Street 1:14000 E 980 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61846-7511
Mailing Address - Country:US
Mailing Address - Phone:718-578-1318
Mailing Address - Fax:
Practice Address - Street 1:3808 UNION ST STE 3K
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5670
Practice Address - Country:US
Practice Address - Phone:718-578-1318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty