Provider Demographics
NPI:1306371356
Name:AVERILL, SAMANTHA HEIDRICH (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:HEIDRICH
Last Name:AVERILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:RACHEL
Other - Last Name:HEIDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-948-7208
Practice Address - Fax:317-944-7247
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084042A2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300065283Medicaid