1164492021 NPI number — VICTORIA R SAMUELS M.D.

Table of content: VICTORIA R SAMUELS M.D. (NPI 1164492021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164492021 NPI number — VICTORIA R SAMUELS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMUELS
Provider First Name:
VICTORIA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1164492021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751069
Provider Second Line Business Mailing Address:
ECU PHYSICIANS
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 COUNTRY DAY RD
Provider Second Line Business Practice Location Address:
GOLDSBORO NEUROLOGICAL SURGERY
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27530-8888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-731-4048
Provider Business Practice Location Address Fax Number:
252-731-2402
Provider Enumeration Date:
01/24/2006

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: 207T00000X , with the licence number:  14997 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 014997 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 2014-00571 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 149976 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164492021 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 185WF . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1164492021 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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