Healthcare Provider Details

I. General information

NPI: 1558031476
Provider Name (Legal Business Name): SAMUEL ADEOYE LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 N BROADWAY ST
CHICAGO IL
60613-2110
US

IV. Provider business mailing address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 773-388-1600
  • Fax: 773-388-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.104124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: