1053546572 NPI number — LYNN H SAMUEL MD LLC

Table of content: (NPI 1053546572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053546572 NPI number — LYNN H SAMUEL MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNN H SAMUEL MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1053546572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
493 BLACKWELL ROAD
Provider Second Line Business Mailing Address:
SUITE 101A
Provider Business Mailing Address City Name:
WARRENTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20186-2628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-316-5604
Provider Business Mailing Address Fax Number:
540-316-5601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
493 BLACKWELL ROAD
Provider Second Line Business Practice Location Address:
SUITE 101A
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20186-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-316-5604
Provider Business Practice Location Address Fax Number:
540-316-5601
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUEL
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-316-5604

Provider Taxonomy Codes

  • Taxonomy code: 207PE0005X , with the licence number:  0101044708 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X , with the licence number: 0101044708 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DP4396 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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