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NPI Code Detail

MEDICARE: DR. PORNTHEP TANPOWPONG M.D.

MEDICARE: DR. PORNTHEP TANPOWPONG 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
1390200000XStudent in an Organized Health Care Education/Training ProgramIL

General Provider Information

NPI Number : 1962690974
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PORNTHEP TANPOWPONG M.D.
Provider Business Mailing Address
First Line : 1117 N DEARBORN ST
Second Line : APT 816
City : CHICAGO
State : IL
Zip : 60610-2701
Country : US
Telephone Number : 773-341-8090
Fax Number :
Provider Business Practice Location Address
First Line : 1117 N DEARBORN ST
Second Line : APT 816
City : CHICAGO
State : IL
Zip : 60610-2701
Country : US
Telephone Number : 773-341-8090
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2007
Last Update Date : 10/04/2007

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