Provider Demographics
NPI:1902545056
Name:OSEI BOATENG, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:OSEI BOATENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 S LAKE PARK AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1420
Mailing Address - Country:US
Mailing Address - Phone:773-526-9096
Mailing Address - Fax:
Practice Address - Street 1:5100 S DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4118
Practice Address - Country:US
Practice Address - Phone:773-966-5039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL344408315Medicaid