=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518306570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YUTTANA CHAWENGSUB M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2013
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 MERCY DR
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-524-4001
-----------------------------------------------------
Fax | 712-325-2499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 MERCY DR
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-524-4001
-----------------------------------------------------
Fax | 712-325-2499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 125063902
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD61203457
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 04-40350
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD2022-1256
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | CP1338
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | MD-43157
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------