Provider Demographics
NPI:1619691748
Name:RHOADES, SAM (PA-C)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:RHOADES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1557
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 330
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1674
Practice Address - Country:US
Practice Address - Phone:260-494-3484
Practice Address - Fax:260-969-0188
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003816A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant