MEDICARE: SAMUEL PORIZA AU M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	35081855	OH
2	2085R0001X	Radiation Oncology Physician	036117479	IL
3	2085R0001X	Radiation Oncology Physician	13493	NV
4	2085R0001X	Radiation Oncology Physician	ME114482	FL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00885629	OTHER	NV	RAILROAD MEDICARE
9	GV509Z	OTHER	FL	MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	880457	OTHER	NV	USA MCO
4	1624235	OTHER	NV	GHI
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	6054447	OTHER	NV	CIGNA

NPI Number	:	1578565420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL PORIZA AU M.D.

Provider Business Mailing Address
First Line	:	301 N 8TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1041
Country	:	US
Telephone Number	:	217-525-5666
Fax Number	:	217-757-6754

Provider Business Practice Location Address
First Line	:	301 N 8TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1041
Country	:	US
Telephone Number	:	217-525-5666
Fax Number	:	217-757-6754

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	10/19/2015

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039

301 N 8TH ST
SPRINGFIELD, IL
62701-1041