Provider Demographics
NPI:1104949635
Name:SAMUEL, JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:8400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3735
Practice Address - Country:US
Practice Address - Phone:262-884-4088
Practice Address - Fax:262-884-4078
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53694207P00000X
IL036126828207P00000X
IL036-126828207Q00000X
WI53694-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100012273Medicaid