Provider Demographics
NPI:1427036052
Name:CHARO, BAMPEN (MD)
Entity Type:Individual
Prefix:
First Name:BAMPEN
Middle Name:
Last Name:CHARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BAMPEN
Other - Middle Name:
Other - Last Name:CHAROENCHITPISARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-528-4253
Mailing Address - Fax:317-865-8319
Practice Address - Street 1:3800 W 203RD ST
Practice Address - Street 2:STE 202
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1184
Practice Address - Country:US
Practice Address - Phone:708-679-2660
Practice Address - Fax:708-503-3861
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046854207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
01616205OtherBLUE SHIELD
IL05-0540914OtherWELLGROUP TAX ID
010025527OtherRR MEDICARE
IL036046854Medicaid
IL05-0540914OtherWELLGROUP TAX ID
010025527OtherRR MEDICARE
IL647790Medicare ID - Type Unspecified
IL203980014Medicare PIN