Provider Demographics
NPI:1073035382
Name:SAMPANG, FREDERICK DUANE (PT, DPT)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:DUANE
Last Name:SAMPANG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 N ARTESIAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3992
Mailing Address - Country:US
Mailing Address - Phone:847-293-8171
Mailing Address - Fax:
Practice Address - Street 1:125 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-3663
Practice Address - Country:US
Practice Address - Phone:847-773-0298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist