Individual
MEDHA SUWANAWONGSE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
121 N 13TH ST, HERRIN, IL 62948-3248
(618) 988-6025
(618) 988-6024
Mailing address
PO BOX 129, 121 NORTH 13TH STREET, HERRIN, IL 62948-0129
(618) 988-6025
(618) 988-6024
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036087814
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
020048410
MEDICARE RAILROAD
—
05
—
036087814
—
IL
01
—
09127249
BCBS
—
01
—
259925
HEALTHLINK
IL
01
—
621141230A
HEALTH ALLIANCE
IL
Enumeration date
08/09/2006
Last updated
07/23/2008
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