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General NPI Number Information
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NPI Number | 1356749261
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Entity Type | Organization
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Legal Business Name | SURASAK AND SIRIMON
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Dates
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Enumeration Date | 12/09/2014
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Last Update Date | 12/09/2014
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Provider Practice Location Address
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Address Line | 1222 LATHROP AVE
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City | RIVER FOREST
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State | IL
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Zip | 60305-1116
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Country | US
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Telephone | 708-218-6645
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Fax |
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Provider Business Mailing Address
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Address Line | 1222 LATHROP AVE
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City | RIVER FOREST
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State | IL
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Zip | 60305-1116
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Country | US
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Telephone | 708-218-6645
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SURASAK PRATUANGTHAM
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Credential | M.D.
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Telephone | 708-218-6645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0208X
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Taxonomy Name | Pediatric Infectious Diseases Physician
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License Number | 036085443
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License Number State | IL
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