MEDICARE: DR. SAMUEL STEPHENS KINGSLEY MD

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	208600000X	Surgery Physician	036.122553	IL

General Provider Information

NPI Number	:	1477851673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL STEPHENS KINGSLEY MD

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:	847-390-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	836 W WELLINGTON AVE RM 4813CC
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5147
Country	:	US
Telephone Number	:	773-296-5073
Fax Number	:	773-296-7199

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

Provider Enumeration Date	:	03/11/2011
Last Update Date	:	03/20/2025

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