Provider Demographics
NPI:1508814419
Name:WAT, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WAT
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 1:185 PENNY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1454
Mailing Address - Country:US
Mailing Address - Phone:847-836-7015
Mailing Address - Fax:847-428-9291
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:RUSH COPLEY MEMORIAL HOSPITAL
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:630-978-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078892207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE49134Medicare UPIN
ILL93996Medicare PIN
ILK51330Medicare PIN