Basic Information
| Provider Information | |||||||||
| NPI: | 1427036052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARO | ||||||||
| FirstName: | BAMPEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CHAROENCHITPISARN | ||||||||
| OtherFirstName: | BAMPEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284253 | ||||||||
| FaxNumber: | 3178658319 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 W 203RD ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086792660 | ||||||||
| FaxNumber: | 7085033861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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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 | 207RP1001X | 036046854 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 01616205 | 01 | BLUE SHIELD | OTHER | 05-0540914 | 01 | IL | WELLGROUP TAX ID | OTHER | 010025527 | 01 | RR MEDICARE | OTHER | 036046854 | 05 | IL | MEDICAID |