Provider Demographics
NPI:1942339676
Name:KIM, CHANG CHOO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:CHOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:35425 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1687
Mailing Address - Country:US
Mailing Address - Phone:734-467-7600
Mailing Address - Fax:734-467-7646
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1687
Practice Address - Country:US
Practice Address - Phone:734-467-7600
Practice Address - Fax:734-467-7646
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032796101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46944Medicare UPIN