Provider Demographics
NPI:1760909287
Name:ORTEGA, SAMUEL (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 S MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-4510
Mailing Address - Country:US
Mailing Address - Phone:708-699-4403
Mailing Address - Fax:
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-681-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041363873367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered