Basic Information
| Provider Information | |||||||||
| NPI: | 1902883648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAXENA | ||||||||
| FirstName: | SAMIR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35080113S | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35-080113 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 809840 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 2345831 | 05 | OH | MEDICAID |