Basic Information
| Provider Information | |||||||||
| NPI: | 1649402702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHIROM BURANAKUL MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618328513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174425863 | ||||||||
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| Practice Location | |||||||||
| Address1: | 102 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618328513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174425863 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2009 | ||||||||
| LastUpdateDate: | 08/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | BURANAKUL | ||||||||
| AuthorizedOfficialFirstName: | BHIROM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2174425863 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.