MEDICARE: PONG MEDICAL CENTER LLC

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	207Q00000X	Family Medicine Physician	036048043	IL

General Provider Information

NPI Number	:	1871853259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONG MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	11110 MARTINDALE DR
Second Line	:
City	:	WESTCHESTER
State	:	IL
Zip	:	60154-4920
Country	:	US
Telephone Number	:	773-218-9625
Fax Number	:	773-784-6173

Provider Business Practice Location Address
First Line	:	5151 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2520
Country	:	US
Telephone Number	:	773-784-0900
Fax Number	:	773-784-6173

Authorized Official
Title or Position	:	MD
Name	:	DR. SUCHAT PONGLORPISITA
Credential	:	MD
Telephone Number	:	773-218-9625

Provider Enumeration Date	:	05/20/2012
Last Update Date	:	05/24/2016

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