Basic Information
| Provider Information | |||||||||
| NPI: | 1780879213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUHAILY | ||||||||
| FirstName: | SAMER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 602 WEST UNIVERSITY AVENUE | ||||||||
| Address2: | NCW4 - PROVIDER ENROLLMENT SPECIALIST | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173262856 | ||||||||
| Practice Location | |||||||||
| Address1: | 4309 W MEDICAL CENTER DR STE B202 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8153853256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A100357 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036.118507 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 12457 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | 036118507 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 036118507 | 01 | IL | STATE LICENSE | OTHER |