Healthcare Provider Details

I. General information

NPI: 1861431264
Provider Name (Legal Business Name): VIRANUJ SUEBLINVONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON RD NE 4TH FLOOR
ATLANTA GA
30322-4200
US

IV. Provider business mailing address

PULMONARY CLINIC 1365A CLIFTON ROAD, 4TH FLOOR
ATLANTA GA
30322-0001
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-107280
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036-107280
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036-107280
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number061664
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number061664
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: