1134138126 NPI number — ROBIN RENEE SAMFORD LSA

Table of content: ROBIN RENEE SAMFORD LSA (NPI 1134138126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134138126 NPI number — ROBIN RENEE SAMFORD LSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMFORD
Provider First Name:
ROBIN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSA
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:
1134138126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 W 5TH STREET #470
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-580-8330
Provider Business Mailing Address Fax Number:
432-580-8333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 W 5TH ST STE 470
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-5070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-580-8330
Provider Business Practice Location Address Fax Number:
432-580-8333
Provider Enumeration Date:
08/07/2006

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: 246ZS0410X , with the licence number:  SA00093 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00455Q . This is a "MEDICARE PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 071693 . This is a "NATNL CERT SURGICAL TECH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: SA00093 . This is a "TEXAS STATE BOARD OF MEDI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 83628 . This is a "NAT CERT SURGICAL TECH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F0641 . This is a "BLUE CROSS PROVIDER #" identifier . This identifiers is of the category "OTHER".




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