Provider Demographics
NPI:1689624470
Name:BAZ, SAMUEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:T
Last Name:BAZ
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 1:516 S CHESTNUT ST
Mailing Address - Street 2:PO BOX 250
Mailing Address - City:WENONA
Mailing Address - State:IL
Mailing Address - Zip Code:61377-0250
Mailing Address - Country:US
Mailing Address - Phone:815-853-4402
Mailing Address - Fax:815-853-4200
Practice Address - Street 1:516 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WENONA
Practice Address - State:IL
Practice Address - Zip Code:61377-0250
Practice Address - Country:US
Practice Address - Phone:815-853-4402
Practice Address - Fax:815-853-4200
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006200024OtherBLUE CROSS/BLUE SHIELD
IL017560OtherHEALTH ALLIANCE
IL4581199OtherAETNA
ILC38574Medicare UPIN
IL0006200024OtherBLUE CROSS/BLUE SHIELD