Healthcare Provider Details

I. General information

NPI: 1700283868
Provider Name (Legal Business Name): MICHAEL BUMROONGSUK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 N YORK ST SUITE 300
ELMHURST IL
60126-2766
US

IV. Provider business mailing address

275 N YORK ST SUITE 300
ELMHURST IL
60126-2766
US

V. Phone/Fax

Practice location:
  • Phone: 630-279-4852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070020981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: