Provider Demographics
NPI:1720099500
Name:DRS. BANUCHI AND BANUCHI, S.C.
Entity Type:Organization
Organization Name:DRS. BANUCHI AND BANUCHI, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRIRAT
Authorized Official - Middle Name:
Authorized Official - Last Name:BANUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-545-3123
Mailing Address - Street 1:4849 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-5100
Mailing Address - Country:US
Mailing Address - Phone:773-545-3123
Mailing Address - Fax:773-545-3886
Practice Address - Street 1:4849 N MILWAUKEE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-5100
Practice Address - Country:US
Practice Address - Phone:773-545-3123
Practice Address - Fax:773-545-3886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360468271207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1615456OtherBLUE SHIELD
IL1615456OtherBLUE SHIELD
ILD12523Medicare UPIN