Healthcare Provider Details

I. General information

NPI: 1568389385
Provider Name (Legal Business Name): SAMIR QATTUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 BLACKWOLF RD
SPRINGFIELD IL
62711-7894
US

IV. Provider business mailing address

5101 BLACKWOLF RD
SPRINGFIELD IL
62711-7894
US

V. Phone/Fax

Practice location:
  • Phone: 217-741-2535
  • Fax:
Mailing address:
  • Phone: 217-741-2535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberQ35079269264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: