Healthcare Provider Details

I. General information

NPI: 1174522189
Provider Name (Legal Business Name): PRAMERN SRIRATANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 HUNT DR
NORMAL IL
61761-2192
US

IV. Provider business mailing address

1606 HUNT DR
NORMAL IL
61761-2192
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-9701
  • Fax: 309-454-1957
Mailing address:
  • Phone: 309-452-9701
  • Fax: 309-454-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036050943
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036050943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: