Healthcare Provider Details

I. General information

NPI: 1811419203
Provider Name (Legal Business Name): SAMUEL J WAINWRIGHT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/27/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST CLINICAL SCIENCES NORTH 440, M/C 718
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

840 S WOOD ST CLINICAL SCIENCES NORTH 440, M/C 718
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4242
  • Fax:
Mailing address:
  • Phone: 312-996-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036156731
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number271799
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036156731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: