Provider Demographics
NPI:1578612982
Name:ABDO, SAMIR FARES (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:FARES
Last Name:ABDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:117 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2702
Mailing Address - Country:US
Mailing Address - Phone:618-252-8625
Mailing Address - Fax:618-252-2540
Practice Address - Street 1:1306 MAPLE ST.
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-297-9609
Practice Address - Fax:618-273-2504
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36063628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360636282Medicaid
IL200601Medicare ID - Type Unspecified
ILC45166Medicare UPIN