Provider Demographics
NPI:1700065398
Name:JOHN A.CHANASUE, M.D.LTD
Entity Type:Organization
Organization Name:JOHN A.CHANASUE, M.D.LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHANASUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-462-9623
Mailing Address - Street 1:307 HENRY ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6326
Mailing Address - Country:US
Mailing Address - Phone:618-462-9623
Mailing Address - Fax:618-462-8591
Practice Address - Street 1:307 HENRY ST
Practice Address - Street 2:STE 200
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6326
Practice Address - Country:US
Practice Address - Phone:618-462-9623
Practice Address - Fax:618-462-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA10166Medicare UPIN