Healthcare Provider Details

I. General information

NPI: 1699648360
Provider Name (Legal Business Name): SAMIKA BASKERVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2025
Last Update Date: 09/27/2025
Certification Date: 09/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE 6004
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

9758 S LUELLA AVE
CHICAGO IL
60617-4864
US

V. Phone/Fax

Practice location:
  • Phone: 217-291-8880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: