Basic Information
| Provider Information | |||||||||
| NPI: | 1174554851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | GENE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 NORTH 39TH STREET | ||||||||
| Address2: | 4 PHI | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
| FaxNumber: | 2156150500 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 NORTH 39TH STREET | ||||||||
| Address2: | 4 PHI | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | MD058220L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 0017558340001 | 05 | PA | MEDICAID |