Healthcare Provider Details

I. General information

NPI: 1740845395
Provider Name (Legal Business Name): SAMIR A SHARRAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W US ROUTE 6 STE 100
MORRIS IL
60450-3370
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-942-4875
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.181339
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036.181339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: