Basic Information
| Provider Information | |||||||||
| NPI: | 1124284401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMET | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E CHICAGO AVE, BOX 09, DEPT. OF MEDICAL IMAGING | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122273502 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 E CHICAGO AVE, DEPT. OF MEDICAL IMAGING | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122273502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 036-124632 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 125052416 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 36-124632 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 125052416 | 01 | IL | TEMPORARY ILLINOIS PHYSICIAN LICENSE | OTHER | 056010300 | 05 | MD | MEDICAID |