Basic Information
| Provider Information | |||||||||
| NPI: | 1073514642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOONJARERN | ||||||||
| FirstName: | SAMPANTA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603024420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084924531 | ||||||||
| FaxNumber: | 7087630970 | ||||||||
| Practice Location | |||||||||
| Address1: | 297 FRANCISCAN DR | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463074858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196221718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01027321A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 000000095595 | 01 | IN | ANTHEM BCBS NUMBER | OTHER | 100168430A | 05 | IN | MEDICAID | 100082060 | 05 | IN | MEDICAID | 090001077 | 01 | IL | IL BCBS NUMBER | OTHER |