MEDICARE: SAMUELS CARE CENTER S C

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	207Q00000X	Family Medicine Physician	036101746	IL

General Provider Information

NPI Number	:	1356537278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMUELS CARE CENTER S C

Provider Business Mailing Address
First Line	:	1130 S WABASH AVE
Second Line	:	SUITE 305
City	:	CHICAGO
State	:	IL
Zip	:	60605-2372
Country	:	US
Telephone Number	:	312-212-1159
Fax Number	:	312-212-1184

Provider Business Practice Location Address
First Line	:	1130 S WABASH AVE
Second Line	:	SUITE 305
City	:	CHICAGO
State	:	IL
Zip	:	60605-2372
Country	:	US
Telephone Number	:	312-212-1159
Fax Number	:	312-212-1184

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VICKI R SAMUELS
Credential	:	M.D.
Telephone Number	:	312-212-1159

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	03/04/2013

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