=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710153762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAJORNDEJ KOMUTANON MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3218 W LAWRENCE AVENUE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-588-6846
-----------------------------------------------------
Fax | 773-588-6847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6543 W ALBERT AVENUE
-----------------------------------------------------
City | MORTON GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60053-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-966-1957
-----------------------------------------------------
Fax | 847-966-1957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KAJORNDEJ KOMUTANON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-966-1957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 036046966
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------