Provider Demographics
NPI:1871827147
Name:DEAN, SAMMY T (MD)
Entity Type:Individual
Prefix:
First Name:SAMMY
Middle Name:T
Last Name:DEAN
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 1:901 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-1821
Mailing Address - Country:US
Mailing Address - Phone:815-943-8090
Mailing Address - Fax:815-943-2188
Practice Address - Street 1:901 GRANT ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-1821
Practice Address - Country:US
Practice Address - Phone:815-943-8090
Practice Address - Fax:815-943-2188
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123329207L00000X, 207LP2900X
WI54353-020207L00000X
TXQ2657207LP2900X
AZ68136207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871827147Medicaid
WIDEANSAMOtherMERCYCARE INSURANCE
IL036123329 2Medicaid
WIDEANSAMOtherMERCYCARE INSURANCE
WI541760972Medicare PIN