Healthcare Provider Details

I. General information

NPI: 1407084726
Provider Name (Legal Business Name): SAMYRA C SEALY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 ODONNELL ST
BALTIMORE MD
21224-5269
US

IV. Provider business mailing address

1340 S DAMEN AVE STE 400
CHICAGO IL
60608-1169
US

V. Phone/Fax

Practice location:
  • Phone: 312-262-2739
  • Fax: 312-564-4059
Mailing address:
  • Phone: 312-262-2739
  • Fax: 312-564-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD71875
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: