Provider Demographics
NPI:1538298872
Name:S PONGCHED MD LTD
Entity Type:Organization
Organization Name:S PONGCHED MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPACHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUWATANAPONGCHED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-596-2445
Mailing Address - Street 1:211 ELGIN AVE
Mailing Address - Street 2:6M
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1382
Mailing Address - Country:US
Mailing Address - Phone:708-596-2445
Mailing Address - Fax:630-455-9633
Practice Address - Street 1:11416 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4932
Practice Address - Country:US
Practice Address - Phone:773-660-8515
Practice Address - Fax:630-455-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAP5130543OtherD.E.A.
ILD12390Medicare UPIN