Healthcare Provider Details

I. General information

NPI: 1881609295
Provider Name (Legal Business Name): MARWAN ABDUL SAMAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8224 CALUMET AVE
MUNSTER IN
46321-1704
US

IV. Provider business mailing address

8224 CALUMET AVE
MUNSTER IN
46321-1704
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1855
  • Fax: 219-836-0527
Mailing address:
  • Phone: 219-836-1855
  • Fax: 219-836-0527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01040993A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: