Healthcare Provider Details

I. General information

NPI: 1164529087
Provider Name (Legal Business Name): SIRIRAT R BANUCHI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 N MILWAUKEE AVE
CHICAGO IL
60630-5100
US

IV. Provider business mailing address

4849 N MILWAUKEE AVE
CHICAGO IL
60630-5100
US

V. Phone/Fax

Practice location:
  • Phone: 773-545-3123
  • Fax: 773-545-3886
Mailing address:
  • Phone: 773-545-3123
  • Fax: 773-545-3886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number36046827
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: