Healthcare Provider Details

I. General information

NPI: 1366452443
Provider Name (Legal Business Name): MEDHA SUWANAWONGSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MEHTA SUWANA MD

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N 13TH ST
HERRIN IL
62948-3248
US

IV. Provider business mailing address

PO BOX 129 121 NORTH 13TH STREET
HERRIN IL
62948-0129
US

V. Phone/Fax

Practice location:
  • Phone: 618-988-6025
  • Fax: 618-988-6024
Mailing address:
  • Phone: 618-988-6025
  • Fax: 618-988-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036087814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: