Healthcare Provider Details

I. General information

NPI: 1578565420
Provider Name (Legal Business Name): SAMUEL PORIZA AU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

301 N 8TH ST
SPRINGFIELD IL
62701-1041
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-5666
  • Fax: 217-757-6754
Mailing address:
  • Phone: 217-525-5666
  • Fax: 217-757-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35081855
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036117479
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number13493
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME114482
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier007934500
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier543382
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 3
Identifier880457
Identifier TypeOTHER
Identifier StateNV
Identifier IssuerUSA MCO
# 4
Identifier1624235
Identifier TypeOTHER
Identifier StateNV
Identifier IssuerGHI
# 5
IdentifierP00885629
Identifier TypeOTHER
Identifier StateNV
Identifier IssuerRAILROAD MEDICARE
# 6
Identifier1578565420
Identifier TypeMEDICAID
Identifier StateNV
Identifier Issuer
# 7
Identifier2368816
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 8
Identifier6054447
Identifier TypeOTHER
Identifier StateNV
Identifier IssuerCIGNA
# 9
IdentifierGV509Z
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerMEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: