Healthcare Provider Details

I. General information

NPI: 1639164601
Provider Name (Legal Business Name): SURASAK PRATUANGTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

8100 W 119TH ST STE 400
PALOS PARK IL
60464-3080
US

V. Phone/Fax

Practice location:
  • Phone: 708-727-1267
  • Fax:
Mailing address:
  • Phone: 708-361-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number036085443
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: