MEDICARE: PORNCHAI JONGLERTHAM 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	207RH0003X	Hematology & Oncology Physician	15910	MS
2	207RH0003X	Hematology & Oncology Physician	N0144	TX
3	207RH0003X	Hematology & Oncology Physician	24180	NE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00436187	OTHER		RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00195	OTHER	NE	BC/BS INDIVIDUAL NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	252609	OTHER		MIDLANDS CHOICE

General Provider Information

NPI Number	:	1265567242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PORNCHAI JONGLERTHAM MD

Provider Business Mailing Address
First Line	:	815 N KANSAS AVE
Second Line	:
City	:	HASTINGS
State	:	NE
Zip	:	68901-4470
Country	:	US
Telephone Number	:	402-460-5899
Fax Number	:	402-460-5898

Provider Business Practice Location Address
First Line	:	815 N KANSAS AVE
Second Line	:
City	:	HASTINGS
State	:	NE
Zip	:	68901-4470
Country	:	US
Telephone Number	:	402-460-5899
Fax Number	:	402-460-5898

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

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	09/10/2018

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