Basic Information
| Provider Information | |||||||||
| NPI: | 1245644384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1653 W CONGRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4545 E 9TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033274700 | ||||||||
| FaxNumber: | 3033274711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-065333 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 270421 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 036.148940 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.