Provider Demographics
NPI:1073520136
Name:WANG, SAM (DC)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:STE 301N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-468-1824
Mailing Address - Fax:
Practice Address - Street 1:149 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1400
Practice Address - Country:US
Practice Address - Phone:224-207-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02230328OtherBCBS
U87358Medicare UPIN
IL02230328OtherBCBS