Basic Information
| Provider Information | |||||||||
| NPI: | 1639165467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCI | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4300 COMMERCE CT | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | LISLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605323698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309681881 | ||||||||
| FaxNumber: | 6302459098 | ||||||||
| Practice Location | |||||||||
| Address1: | 4115 FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605152268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309681881 | ||||||||
| FaxNumber: | 6309683762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 016003414 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0000X | 016003414 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Sports Medicine | 213ES0103X | 016003414 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 016003414 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213E00000X | 016003414 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 016003414 | 05 | IL | MEDICAID | 480007268 | 01 | IL | RAILROAD MEDICARE | OTHER |