1053491837 NPI number — DAVID E SAMUEL DPM

Table of content: DAVID E SAMUEL DPM (NPI 1053491837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053491837 NPI number — DAVID E SAMUEL DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMUEL
Provider First Name:
DAVID
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1053491837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 W SPROUL RD STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19064-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-328-9122
Provider Business Mailing Address Fax Number:
610-328-6219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 W SPROUL RD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19064-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-328-9122
Provider Business Practice Location Address Fax Number:
610-328-6219
Provider Enumeration Date:
10/16/2006

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: 213ES0103X , with the licence number:  SC003536L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3323 . This is a "ELDER HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0549291000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 480021835 . This is a "PALMETTO/RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4973770001 . This is a "NHIC/DMERC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1643217 . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 712999 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 00130001000004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010163 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2317760000 . This is a "KEYSTONE HEALTH GROUP NUM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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