MEDICARE: VIRACH ANANTACHAI MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	13217	NE

General Provider Information

NPI Number	:	1013011766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRACH ANANTACHAI MD PC

Provider Business Mailing Address
First Line	:	PO BOX 527
Second Line	:	130 N 6TH STREET
City	:	LOUP CITY
State	:	NE
Zip	:	68853-0527
Country	:	US
Telephone Number	:	308-745-0514
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 N 6TH STREET
Second Line	:
City	:	LOUP CITY
State	:	NE
Zip	:	68853-0527
Country	:	US
Telephone Number	:	308-745-0514
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VIRACH ANANTACHAI
Credential	:	MD
Telephone Number	:	308-745-0514

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	04/20/2008

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