Provider Demographics
NPI:1932140118
Name:CHEN, CHONG (MD)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:
Last Name:CHEN
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 1:12251 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-6427
Mailing Address - Country:US
Mailing Address - Phone:773-928-6777
Mailing Address - Fax:773-928-1280
Practice Address - Street 1:12251 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-6427
Practice Address - Country:US
Practice Address - Phone:773-928-6777
Practice Address - Fax:773-928-1280
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12920Medicare UPIN
IL484540Medicare ID - Type Unspecified