Individual
SAMANTHA GHANAYEM BOUIKIDIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10400 75TH ST, KENOSHA, WI 53142-7884
(262) 948-7370
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
125065487
IL
207Q00000X
Family Medicine Physician
Primary
67162
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100070028
—
WI
05
—
1588083232
—
WI
Enumeration date
04/09/2014
Last updated
11/13/2023
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