Provider Demographics
NPI:1346243169
Name:APPAVU, SAMUEL K (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:K
Last Name:APPAVU
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:PO BOX 15730
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5730
Mailing Address - Country:US
Mailing Address - Phone:815-964-3333
Mailing Address - Fax:815-964-3134
Practice Address - Street 1:2300 N ROCKTON AVE
Practice Address - Street 2:STE 304
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-964-3333
Practice Address - Fax:815-964-3134
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048085208600000X, 173000000X, 2086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No173000000XOther Service ProvidersLegal Medicine
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204575400OtherOWCP
IL036048085 1Medicaid
IL036048085OtherSTATE LICENSE
194281OtherPERSONAL CARE
ILC43118Medicare UPIN
IL036048085OtherSTATE LICENSE
194281OtherPERSONAL CARE