Basic Information
| Provider Information | |||||||||
| NPI: | 1962513952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATHANACHAROEN | ||||||||
| FirstName: | SUCHINT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035889000 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | PROFESSIONAL SERVICES OF KU HOSPITAL | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135887743 | ||||||||
| FaxNumber: | 9135889786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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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 | 208600000X | 04-17385 | KS | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 04-17385 | KS | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 04-17385 | KS | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 03077025 | 01 | BCBS PSKU PROVIDER NUMBER | OTHER | 4002033 | 01 | AETNA | OTHER | 513021 | 01 | PSKU FIRSTGUARD | OTHER | 10001081901 | 01 | CHP PROVIDER NUMBER | OTHER |