Provider Demographics
NPI:1538422217
Name:CHANGCHAROEN, BHISIT (MD)
Entity type:Individual
Prefix:
First Name:BHISIT
Middle Name:
Last Name:CHANGCHAROEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-1788
Practice Address - Fax:803-774-9113
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC38478208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC384783Medicaid
SCSC8480F694OtherMEDICARE
SCSC8480F694Medicare PIN