Healthcare Provider Details

I. General information

NPI: 1376293845
Provider Name (Legal Business Name): SAMANTHA REYNA CASTILLO-MALLORY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA NICOLE MALLORY

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 312-942-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.180427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: