Provider Demographics
NPI:1366452443
Name:SUWANAWONGSE, MEDHA (MD)
Entity Type:Individual
Prefix:
First Name:MEDHA
Middle Name:
Last Name:SUWANAWONGSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MEHTA
Other - Middle Name:
Other - Last Name:SUWANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:121 NORTH 13TH STREET
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-0129
Mailing Address - Country:US
Mailing Address - Phone:618-988-6025
Mailing Address - Fax:618-988-6024
Practice Address - Street 1:121 N 13TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3248
Practice Address - Country:US
Practice Address - Phone:618-988-6025
Practice Address - Fax:618-988-6024
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087814208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
09127249OtherBCBS
020048410OtherMEDICARE RAILROAD
IL036087814Medicaid
IL621141230AOtherHEALTH ALLIANCE
IL259925OtherHEALTHLINK
624790Medicare PIN
IL621141230AOtherHEALTH ALLIANCE