Provider Demographics
NPI:1134150360
Name:CONRAD, SAMANTHA B (MD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:B
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:331 W SURF ST STE 700
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-0083
Practice Address - Country:US
Practice Address - Phone:773-832-7443
Practice Address - Fax:773-295-4126
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107758207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK01357Medicare ID - Type Unspecified
ILH21077Medicare UPIN