1750573820 NPI number — MRS. SAMANTHA LEE MILOSZ PA-C

Table of content: MRS. SAMANTHA LEE MILOSZ PA-C (NPI 1750573820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750573820 NPI number — MRS. SAMANTHA LEE MILOSZ PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILOSZ
Provider First Name:
SAMANTHA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1750573820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 W OAKLAND AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-2357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-915-5000
Provider Business Mailing Address Fax Number:
423-915-5045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
378 MARKETPLACE DR STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-282-0751
Provider Business Practice Location Address Fax Number:
423-282-1577
Provider Enumeration Date:
08/13/2007

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: 363AM0700X , with the licence number:  25MP00165800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 011369-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 1649 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1750573820 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1512404 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".