Provider Demographics
NPI:1770637753
Name:CHOMCHAI, CHAIRAT (MD)
Entity type:Individual
Prefix:
First Name:CHAIRAT
Middle Name:
Last Name:CHOMCHAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28111 HOOVER ROAD
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-751-4230
Mailing Address - Fax:586-751-9260
Practice Address - Street 1:28111 HOOVER ROAD
Practice Address - Street 2:SUITE 6A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-751-4230
Practice Address - Fax:586-751-9260
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032652208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1727375Medicaid
A77763Medicare UPIN
MI1727375Medicaid