Healthcare Provider Details

I. General information

NPI: 1255254025
Provider Name (Legal Business Name): FNU SAMIULLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 W PETERSON AVE STE 102
CHICAGO IL
60659-4030
US

IV. Provider business mailing address

700 W RAND RD APT C408
ARLINGTON HEIGHTS IL
60004-8405
US

V. Phone/Fax

Practice location:
  • Phone: 773-943-0322
  • Fax:
Mailing address:
  • Phone: 773-943-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: