Provider Demographics
NPI:1922087725
Name:SAMUELS, VICKI R (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:R
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S RIVERSIDE PLZ STE 2225
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3707
Mailing Address - Country:US
Mailing Address - Phone:312-273-4930
Mailing Address - Fax:
Practice Address - Street 1:10 S RIVERSIDE PLZ STE 2225
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3707
Practice Address - Country:US
Practice Address - Phone:312-273-4930
Practice Address - Fax:312-628-5100
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101746OtherSTATE LICENSE
ILH37994Medicare UPIN