Healthcare Provider Details

I. General information

NPI: 1366496564
Provider Name (Legal Business Name): PANOM PHOUNGCHERDCHOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2529
US

IV. Provider business mailing address

1745 PAVILION WAY UNIT 207
PARK RIDGE IL
60068-1163
US

V. Phone/Fax

Practice location:
  • Phone: 708-771-7000
  • Fax:
Mailing address:
  • Phone: 847-698-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036045322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: