Healthcare Provider Details

I. General information

NPI: 1417943176
Provider Name (Legal Business Name): SAMBHUNDH PANICHABHONGSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S KANSAS RRH PHYSICIANS CLINIC STE B
RUSSELL KS
67665
US

IV. Provider business mailing address

222 S. KANSAS
RUSSELL KS
67665
US

V. Phone/Fax

Practice location:
  • Phone: 785-483-3333
  • Fax: 785-483-0781
Mailing address:
  • Phone: 785-483-3333
  • Fax: 785-483-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16833
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16833
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-16833
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: