Healthcare Provider Details

I. General information

NPI: 1265877849
Provider Name (Legal Business Name): SAMANTHA DOLPH WINERMAN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA DOLPH DPM

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 RIDGE AVE STE 110
EVANSTON IL
60201-2455
US

IV. Provider business mailing address

2500 RIDGE AVE STE 110
EVANSTON IL
60201-2455
US

V. Phone/Fax

Practice location:
  • Phone: 847-475-9030
  • Fax: 847-475-9031
Mailing address:
  • Phone: 847-475-9030
  • Fax: 847-475-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005646
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135000819
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: