Healthcare Provider Details

I. General information

NPI: 1134500283
Provider Name (Legal Business Name): SAMUEL GOODMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 N CLARK ST
CHICAGO IL
60657-4414
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-3833
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5090
  • Fax: 312-766-4925
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036146785
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-146785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: