MEDICARE: VITHIDA SUEBLINVONG MD

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	2080P0202X	Pediatric Cardiology Physician	36099389	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134193121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITHIDA SUEBLINVONG MD

Provider Business Mailing Address
First Line	:	840 S WOOD ST
Second Line	:	M/C 856
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-6605
Fax Number	:	312-413-3373

Provider Business Practice Location Address
First Line	:	840 S WOOD ST
Second Line	:	M/C 856
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-6605
Fax Number	:	312-413-3373

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	12/07/2011

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Directions to “ VITHIDA SUEBLINVONG MD” Practice Location

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