Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036048085 | IL |
Y | 208600000X | Surgeon | 036048085 | IL |
N | 2086S0102X | Surgical Critical Care | 036048085 | IL |
N | 2086S0127X | Trauma Surgeon | 036048085 | IL |
NPI | 1346243169 |
---|---|
Provider Name | Dr. Samuel K Appavu |
First Address | Loves Park, IL 61132-5730 |
Second Address | Rockford, IL 61103-3619 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2005 |
Last Update Date | 02/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036048085 | STATE LICENSE (01) | IL |
036048085 1 | (05) | IL |
194281 | PERSONAL CARE (01) | |
204575400 | OWCP (01) | IL |
C43118 | (02) | IL |