Healthcare Provider Details

I. General information

NPI: 1538404975
Provider Name (Legal Business Name): SOMPONG BUMROONGSUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4853 BIRCHWOOD AVE
SKOKIE IL
60077-3302
US

IV. Provider business mailing address

4813 BIRCHWOOD AVE
SKOKIE IL
60077-3302
US

V. Phone/Fax

Practice location:
  • Phone: 847-673-6698
  • Fax:
Mailing address:
  • Phone: 847-673-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036-047793
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: