Provider Demographics
NPI:1073537643
Name:SAM, RONALD E (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:E
Last Name:SAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE #106
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-422-7758
Mailing Address - Fax:708-422-8154
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE #106
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-422-7758
Practice Address - Fax:708-422-8154
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL336055662207R00000X
LA309875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID200892Medicare ID - Type Unspecified