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
StateLicense IDTaxonomies
MA76235207LC0200X, 207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110051609BMedicaid
MAJ1280501Medicare PIN
RI007058528Medicare PIN
RI7058528Medicaid