Provider Demographics
NPI:1598781577
Name:TEMIYASATHIT, SRIRAT (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIRAT
Middle Name:
Last Name:TEMIYASATHIT
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:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:911 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:IL
Practice Address - Zip Code:61752-1894
Practice Address - Country:US
Practice Address - Phone:309-962-2081
Practice Address - Fax:309-962-9021
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5315769OtherBLUE CROSS BLUE SHIELD
C45796Medicare UPIN
IL206706Medicare ID - Type UnspecifiedMEDICARE GROUP
5315769OtherBLUE CROSS BLUE SHIELD