Basic Information
| Provider Information | |||||||||
| NPI: | 1639623911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERCICH | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| OtherLastName: | SCHLAKE | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4280 S STATE ROUTE 159 | ||||||||
| Address2: | |||||||||
| City: | GLEN CARBON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620343269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2016 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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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 | 2251X0800X | 2016027389 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.