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General NPI Number Information
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NPI Number | 1538298872
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Entity Type | Organization
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Legal Business Name | S PONGCHED MD LTD
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Dates
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Enumeration Date | 03/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11416 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60628-4932
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Country | US
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Telephone | 773-660-8515
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Fax | 630-455-9633
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Provider Business Mailing Address
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Address Line | 211 ELGIN AVE 6M
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City | FOREST PARK
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State | IL
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Zip | 60130-1382
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Country | US
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Telephone | 708-596-2445
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Fax | 630-455-9633
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUPACHAI SUWATANAPONGCHED
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Credential | M.D.
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Telephone | 708-596-2445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State | IL
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