Provider Demographics
NPI:1730115643
Name:GAINES, SAM (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:GAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 COLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3384
Mailing Address - Country:US
Mailing Address - Phone:217-782-9318
Mailing Address - Fax:217-793-5267
Practice Address - Street 1:VIRGINIA & FRANKLIN STREETS
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-827-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057022207P00000X, 207PE0004X
IL036057022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057022-1Medicaid
IL05721369OtherBC/BS
IL036057022Medicaid
110242133Medicare PIN
IL207617Medicare PIN
IL207878Medicare PIN
IL036057022Medicaid
IL036057022-1Medicaid
IL05721369OtherBC/BS