Healthcare Provider Details

I. General information

NPI: 1649237702
Provider Name (Legal Business Name): SAMUEL RAMIREZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5723 W FULLERTON AVE
CHICAGO IL
60639-2306
US

IV. Provider business mailing address

4918 N MAGNOLIA AVE
CHICAGO IL
60640-3507
US

V. Phone/Fax

Practice location:
  • Phone: 773-622-8060
  • Fax: 773-622-8095
Mailing address:
  • Phone: 773-728-0989
  • Fax: 773-728-1062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004751
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: