Basic Information
| Provider Information | |||||||||
| NPI: | 1457878225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAITZMAN | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086344602 | ||||||||
| FaxNumber: | 6304951770 | ||||||||
| Practice Location | |||||||||
| Address1: | 363 W ERIE ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606546933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129951955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-006222 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085-006222 | 01 | IL | STATE LICENSE | OTHER |