Provider Demographics
NPI:1013011766
Name:VIRACH ANANTACHAI MD PC
Entity Type:Organization
Organization Name:VIRACH ANANTACHAI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRACH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANANTACHAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-745-0514
Mailing Address - Street 1:PO BOX 527
Mailing Address - Street 2:130 N 6TH STREET
Mailing Address - City:LOUP CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68853-0527
Mailing Address - Country:US
Mailing Address - Phone:308-745-0514
Mailing Address - Fax:
Practice Address - Street 1:130 N 6TH STREET
Practice Address - Street 2:
Practice Address - City:LOUP CITY
Practice Address - State:NE
Practice Address - Zip Code:68853-0527
Practice Address - Country:US
Practice Address - Phone:308-745-0514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid
093576Medicare PIN