Healthcare Provider Details

I. General information

NPI: 1023923562
Provider Name (Legal Business Name): JEREMY SAMUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

13350 BRITTANY DR
ORLAND PARK IL
60462-1316
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number041527064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: