MEDICARE: DR. ATTAPOOM SUSUPAUS M.D.

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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	125060733	IL

General Provider Information

NPI Number	:	1386918787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ATTAPOOM SUSUPAUS M.D.

Provider Business Mailing Address
First Line	:	355 E OHIO ST UNIT 3504
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-5653
Country	:	US
Telephone Number	:	312-927-5567
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 EAST HURON ST
Second Line	:	GALTER PAVILLION 11-140
City	:	CHICAGO
State	:	IL
Zip	:	60611-2968
Country	:	US
Telephone Number	:	312-695-3662
Fax Number	:

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

Provider Enumeration Date	:	03/02/2012
Last Update Date	:	03/02/2012

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