MEDICARE: SUCHITRA SURAPIBOONCHAI CRNA

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	207L00000X	Anesthesiology Physician		IL

General Provider Information

NPI Number	:	1316948821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUCHITRA SURAPIBOONCHAI CRNA

Provider Business Mailing Address
First Line	:	520 E 22ND ST
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-6110
Country	:	US
Telephone Number	:	630-874-2542
Fax Number	:	630-874-2642

Provider Business Practice Location Address
First Line	:	326 WEST 64TH STREET
Second Line	:	ST. BERNARD HOSPITAL/ANESTHESIA DEPARTMENT
City	:	CHICAGO
State	:	IL
Zip	:	60621
Country	:	US
Telephone Number	:	773-962-4100
Fax Number	:

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/08/2007

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