Basic Information
| Provider Information | |||||||||
| NPI: | 1790896439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NARUNATVANICH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR STE 1000 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606118709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126959494 | ||||||||
| FaxNumber: | 3126956594 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 KISH HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601159602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157561521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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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 | 207P00000X | 036.116278 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 036116278 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 036-116278 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1790896439 | 01 | IL | BLUE SHIELD | OTHER | 036116278 | 05 | IL | MEDICAID | 036116278 | 01 | IL | STATE LICENSE | OTHER |