MEDICARE: DR. SAM S SCOTT D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	038-009636	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1634503	OTHER	IL	BCBS PROVIDOR #

General Provider Information

NPI Number	:	1467508861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAM S SCOTT D.C.

Provider Business Mailing Address
First Line	:	1878 N ORCHARD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-8923
Country	:	US
Telephone Number	:	312-933-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	2834 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5151
Country	:	US
Telephone Number	:	312-933-5155
Fax Number	:	773-549-4776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	07/08/2007

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