Provider Demographics
NPI:1649363656
Name:CHANG, KI M (MD)
Entity type:Individual
Prefix:
First Name:KI
Middle Name:M
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7165 GETWELL RD BLDG F
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9619
Practice Address - Country:US
Practice Address - Phone:662-349-3206
Practice Address - Fax:662-349-3222
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN19945207R00000X
MS12991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119796Medicaid
TN3145336OtherBCBS OF TN
MS110210982Medicaid
MS110210982Medicaid
TN3145336OtherBCBS OF TN