Provider Demographics
NPI:1881323905
Name:ASSAM, SAMUEL (P)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:ASSAM
Suffix:
Gender:M
Credentials:P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 W BOUGHTON RD # B
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2399
Mailing Address - Country:US
Mailing Address - Phone:630-566-2090
Mailing Address - Fax:833-646-2087
Practice Address - Street 1:213 N MORGAN ST UNIT 1D
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1721
Practice Address - Country:US
Practice Address - Phone:312-888-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024296363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2021033717OtherANCC