Provider Demographics
NPI:1962513952
Name:WATHANACHAROEN, SUCHINT (MD)
Entity type:Individual
Prefix:
First Name:SUCHINT
Middle Name:
Last Name:WATHANACHAROEN
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 1:2330 SHAWNEE MISSION PKWY
Mailing Address - Street 2:MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE 312
Mailing Address - City:WESTWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2005
Mailing Address - Country:US
Mailing Address - Phone:903-588-9000
Mailing Address - Fax:913-588-9822
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:PROFESSIONAL SERVICES OF KU HOSPITAL
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-7743
Practice Address - Fax:913-588-9786
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17385208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
03077025OtherBCBS PSKU PROVIDER NUMBER
4002033OtherAETNA
513021OtherPSKU FIRSTGUARD
10001081901OtherCHP PROVIDER NUMBER
4002033OtherAETNA
03077025OtherBCBS PSKU PROVIDER NUMBER