Provider Demographics
NPI:1467508861
Name:SCOTT, SAM S (DC)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:S
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1878 N ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8923
Mailing Address - Country:US
Mailing Address - Phone:312-933-5155
Mailing Address - Fax:
Practice Address - Street 1:2834 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5151
Practice Address - Country:US
Practice Address - Phone:312-933-5155
Practice Address - Fax:773-549-4776
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009636111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634503OtherBCBS PROVIDOR #