Provider Demographics
NPI: | 1851344741 |
---|---|
Name: | CHANG, SU-PEN BOBBY (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SU-PEN BOBBY |
Middle Name: | |
Last Name: | CHANG |
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: | 801 ALBANY ST |
Mailing Address - Street 2: | FL G |
Mailing Address - City: | BOSTON |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02119 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 617-414-5405 |
Mailing Address - Fax: | 617-414-6031 |
Practice Address - Street 1: | 1 BOSTON MEDICAL CTR PL |
Practice Address - Street 2: | |
Practice Address - City: | BOSTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02118-2908 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-638-6950 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-19 |
Last Update Date: | 2020-10-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 76235 | 207LC0200X, 207L00000X, 207LC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | |
No | 207LC0200X | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 110051609B | Medicaid | |
MA | J1280501 | Medicare PIN | |
RI | 007058528 | Medicare PIN | |
RI | 7058528 | Medicaid |