Provider Demographics
NPI:1376158444
Name:SAMUEL, CHARLES (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 N WESTGATE RD APT 222
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2661
Mailing Address - Country:US
Mailing Address - Phone:224-659-6159
Mailing Address - Fax:
Practice Address - Street 1:280 N WESTGATE RD APT 222
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2661
Practice Address - Country:US
Practice Address - Phone:224-659-6159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021993363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner