Provider Demographics
NPI:1548572209
Name:AMPONSAH, SAMUEL K (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:K
Last Name:AMPONSAH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 8TH PKWY
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-6124
Mailing Address - Country:US
Mailing Address - Phone:847-249-9715
Mailing Address - Fax:847-249-1039
Practice Address - Street 1:2419 8TH PKWY
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6124
Practice Address - Country:US
Practice Address - Phone:847-249-9715
Practice Address - Fax:847-249-1039
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist