Healthcare Provider Details

I. General information

NPI: 1265685242
Provider Name (Legal Business Name): SURESH NELSON SAMSON M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 VOLLMER RD
OLYMPIA FIELDS IL
60461-1179
US

IV. Provider business mailing address

PO BOX 3877
JOLIET IL
60434-3877
US

V. Phone/Fax

Practice location:
  • Phone: 708-898-0811
  • Fax:
Mailing address:
  • Phone: 815-741-6830
  • Fax: 815-741-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036-132030
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: