Basic Information
| Provider Information | |||||||||
| NPI: | 1639377963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANGAMIRE | ||||||||
| FirstName: | FREEMAN | ||||||||
| MiddleName: | TICHATONGA | ||||||||
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| Credential: | M.D., SC.D., MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 7926 PRESTON HWY STE 106 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402193848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029644357 | ||||||||
| FaxNumber: | 5029665948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2007 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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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 | 207Q00000X | 244111 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 38679 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 50191 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110086725/A | 05 | MA | MEDICAID | 234001 | 01 | KY | SIHO | OTHER | 386790 | 05 | SC | MEDICAID | 000001121829 | 01 | KY | ANTHEM-KY | OTHER | K231120 | 01 | KY | MEDICARE | OTHER |