Healthcare Provider Details

I. General information

NPI: 1093827727
Provider Name (Legal Business Name): CHANTE THANH TRINH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 14TH ST
HERRIN IL
62948-3631
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-2171
  • Fax: 618-988-6186
Mailing address:
  • Phone: 618-942-2171
  • Fax: 618-351-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-110916
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036-110916
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: