Provider Demographics
NPI:1083935076
Name:TRI, SAMUEL DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:TRI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:TRI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 740018
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0018
Mailing Address - Country:US
Mailing Address - Phone:312-929-9730
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:30 W MONROE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-2495
Practice Address - Country:US
Practice Address - Phone:312-733-9730
Practice Address - Fax:312-929-0373
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA173313207Q00000X
390200000X
NMA-1733-13207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79237371Medicaid