Provider Demographics
NPI:1821353673
Name:SAMANTHA B. CONRAD M.D.S.C
Entity Type:Organization
Organization Name:SAMANTHA B. CONRAD M.D.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-590-1500
Mailing Address - Street 1:1655 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:203E
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3982
Mailing Address - Country:US
Mailing Address - Phone:847-590-1500
Mailing Address - Fax:847-590-1502
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5068
Practice Address - Country:US
Practice Address - Phone:847-590-1500
Practice Address - Fax:847-590-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107758207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107758Medicaid