1780879213 NPI number — DR. SAMER M NUHAILY MD

Table of content: DR. SAMER M NUHAILY MD (NPI 1780879213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780879213 NPI number — DR. SAMER M NUHAILY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUHAILY
Provider First Name:
SAMER
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780879213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 WEST UNIVERSITY AVENUE
Provider Second Line Business Mailing Address:
NCW4 - PROVIDER ENROLLMENT SPECIALIST
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-2530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6792
Provider Business Mailing Address Fax Number:
217-326-2856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 PHALEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55130-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-254-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036.118507 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A100357 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 12457 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 036118507 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 74171 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036118507 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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