Provider Demographics
NPI:1578565420
Name:AU, SAMUEL PORIZA (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PORIZA
Last Name:AU
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 1:301 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1041
Mailing Address - Country:US
Mailing Address - Phone:217-525-5666
Mailing Address - Fax:217-757-6754
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-525-5666
Practice Address - Fax:217-757-6754
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350818552085R0001X
IL0361174792085R0001X
NV134932085R0001X
FLME1144822085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007934500Medicaid
AZ543382Medicaid
NV880457OtherUSA MCO
NV1624235OtherGHI
NVP00885629OtherRAILROAD MEDICARE
NV1578565420Medicaid
OH2368816Medicaid
NV6054447OtherCIGNA
FLGV509ZOtherMEDICARE
OH2368816Medicaid
FL007934500Medicaid
ILK36592Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NV880457OtherUSA MCO
NVDW785ZMedicare PIN