Basic Information
| Provider Information | |||||||||
| NPI: | 1285698738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | SUNG | ||||||||
| MiddleName: | KYU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7351 OLD MOON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319097291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066537000 | ||||||||
| FaxNumber: | 7043773389 | ||||||||
| Practice Location | |||||||||
| Address1: | 7351 OLD MOON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319097291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066537000 | ||||||||
| FaxNumber: | 7066537800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 10/17/2010 | ||||||||
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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 | 207LP2900X | 52693 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 141512294A | 05 | GA | MEDICAID | 511I090013 | 01 | GA | MEDICARE PTAN | OTHER | 52261875-001 | 01 | GA | BCBSGA | OTHER |