Healthcare Provider Details

I. General information

NPI: 1831614700
Provider Name (Legal Business Name): SAMANTHA J KURNIK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA THOMPSON

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5647 W ADDISON ST
CHICAGO IL
60634-4403
US

IV. Provider business mailing address

2232 N CLYBOURN AVE FL 3
CHICAGO IL
60614-3193
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-1830
  • Fax: 773-736-1840
Mailing address:
  • Phone: 312-633-5841
  • Fax: 773-269-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-006266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: