Provider Demographics
NPI:1366496564
Name:PHOUNGCHERDCHOO, PANOM (MD)
Entity type:Individual
Prefix:
First Name:PANOM
Middle Name:
Last Name:PHOUNGCHERDCHOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 PAVILION WAY
Mailing Address - Street 2:UNIT 207
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1163
Mailing Address - Country:US
Mailing Address - Phone:847-698-3470
Mailing Address - Fax:
Practice Address - Street 1:8311 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2529
Practice Address - Country:US
Practice Address - Phone:708-771-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360453222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045322Medicaid
IL036045322Medicaid
ILC40163Medicare UPIN
ILK20302Medicare ID - Type Unspecified