Healthcare Provider Details

I. General information

NPI: 1285144931
Provider Name (Legal Business Name): SAMUEL F WALSTRUM PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 TRACIE DR
LAKE ZURICH IL
60047-3342
US

IV. Provider business mailing address

1927 LINCOLN DR
ANNAPOLIS MD
21401-4118
US

V. Phone/Fax

Practice location:
  • Phone: 224-633-6405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28560
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: