Provider Demographics
NPI:1356749261
Name:SURASAK AND SIRIMON
Entity type:Organization
Organization Name:SURASAK AND SIRIMON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURASAK
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATUANGTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-218-6645
Mailing Address - Street 1:1222 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1116
Mailing Address - Country:US
Mailing Address - Phone:708-218-6645
Mailing Address - Fax:
Practice Address - Street 1:1222 LATHROP AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1116
Practice Address - Country:US
Practice Address - Phone:708-218-6645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360854432080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Single Specialty