1366452443 NPI number — MEDHA SUWANAWONGSE MD

Table of content: MEDHA SUWANAWONGSE MD (NPI 1366452443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366452443 NPI number — MEDHA SUWANAWONGSE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUWANAWONGSE
Provider First Name:
MEDHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUWANA
Provider Other First Name:
MEHTA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366452443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
121 NORTH 13TH STREET
Provider Business Mailing Address City Name:
HERRIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62948-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-988-6025
Provider Business Mailing Address Fax Number:
618-988-6024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 N 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-988-6025
Provider Business Practice Location Address Fax Number:
618-988-6024
Provider Enumeration Date:
08/09/2006

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: 208600000X , with the licence number:  036087814 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09127249 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 020048410 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036087814 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 621141230A . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 259925 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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