Active NPI
Panom Phoungcherdchoo, M.D.
- Psychiatry Physician
- Forest Park, IL
National Provider Identifier
1366496564
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 036045322
- Practice address
- 8311 Roosevelt Rd
Forest Park, IL 60130-2529 - Phone
- (708) 771-7000
- NPI assigned
- May 20, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 036045322 | IL | Primary |
Addresses
Primary practice location
8311 Roosevelt Rd
Forest Park, IL 60130-2529
Mailing address
1745 Pavilion Way
Unit 207
Park Ridge, IL 60068-1163
Phone (847) 698-3470
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036045322 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036045322 | IL | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1148083200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1495411200000",
"number": "1366496564",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1745 PAVILION WAY",
"address_2": "UNIT 207",
"city": "PARK RIDGE",
"state": "IL",
"postal_code": "600681163",
"telephone_number": "847-698-3470"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "8311 ROOSEVELT RD",
"city": "FOREST PARK",
"state": "IL",
"postal_code": "601302529",
"telephone_number": "708-771-7000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHOUNGCHERDCHOO",
"first_name": "PANOM",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-20",
"last_updated": "2017-05-22",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "IL",
"license": "036045322",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036045322",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Forest Park, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.