Provider Demographics
NPI:1174672653
Name:BANCHONGMANIE, RONACHAI (MD)
Entity Type:Individual
Prefix:
First Name:RONACHAI
Middle Name:
Last Name:BANCHONGMANIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 8241
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-8241
Mailing Address - Country:US
Mailing Address - Phone:866-286-9915
Mailing Address - Fax:502-471-2051
Practice Address - Street 1:5341 MITSCHER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2633
Practice Address - Country:US
Practice Address - Phone:502-375-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17611207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64176118Medicaid
KYC74860Medicare UPIN
KY1376101Medicare ID - Type Unspecified