Provider Demographics
NPI:1457448334
Name:REUTRAKUL, SIRIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIRIMON
Middle Name:
Last Name:REUTRAKUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:STE 250
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-6163
Mailing Address - Fax:312-563-2096
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:STE 250
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-6163
Practice Address - Fax:312-563-2096
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092151207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH27136Medicare UPIN