MEDICARE: DR. SAMUEL D DELISI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	036041409	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21604498	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1184728388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL D DELISI M.D.

Provider Business Mailing Address
First Line	:	111 N COUNTY FARM RD
Second Line	:
City	:	WHEATON
State	:	IL
Zip	:	60187-3977
Country	:	US
Telephone Number	:	630-682-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N COUNTY FARM RD
Second Line	:
City	:	WHEATON
State	:	IL
Zip	:	60187-3977
Country	:	US
Telephone Number	:	630-682-7400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	03/12/2010

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