MEDICARE: S PONGCHED MD LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician		IL

General Provider Information

NPI Number	:	1538298872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S PONGCHED MD LTD

Provider Business Mailing Address
First Line	:	211 ELGIN AVE
Second Line	:	6M
City	:	FOREST PARK
State	:	IL
Zip	:	60130-1382
Country	:	US
Telephone Number	:	708-596-2445
Fax Number	:	630-455-9633

Provider Business Practice Location Address
First Line	:	11416 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-4932
Country	:	US
Telephone Number	:	773-660-8515
Fax Number	:	630-455-9633

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SUPACHAI SUWATANAPONGCHED
Credential	:	M.D.
Telephone Number	:	708-596-2445

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	08/22/2020

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