1982664611 NPI number — DR. EDWIN KENNETH CHAN M.D.

Table of content: DR. EDWIN KENNETH CHAN M.D. (NPI 1982664611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982664611 NPI number — DR. EDWIN KENNETH CHAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
EDWIN
Provider Middle Name:
KENNETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAN
Provider Other First Name:
EDWIN
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1982664611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10009-8925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-321-8246
Provider Business Mailing Address Fax Number:
718-321-8273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13640 39TH AVE
Provider Second Line Business Practice Location Address:
SUITE 6GB
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11354-5536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-321-8246
Provider Business Practice Location Address Fax Number:
718-321-8273
Provider Enumeration Date:
03/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  222486 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02655645 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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