Healthcare Provider Details

I. General information

NPI: 1427036052
Provider Name (Legal Business Name): BAMPEN CHARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BAMPEN CHAROENCHITPISARN MD

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 203RD ST STE 202
OLYMPIA FIELDS IL
60461-1184
US

IV. Provider business mailing address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7240
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2660
  • Fax: 708-503-3861
Mailing address:
  • Phone: 317-528-4253
  • Fax: 317-865-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036046854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: