1154318632 NPI number — DR. DEBRA R CRITES-SAMS DO

Table of content: DR. DEBRA R CRITES-SAMS DO (NPI 1154318632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154318632 NPI number — DR. DEBRA R CRITES-SAMS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRITES-SAMS
Provider First Name:
DEBRA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMS
Provider Other First Name:
DEBRA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1154318632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 465
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RONCEVERTE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24970-0465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-645-4406
Provider Business Mailing Address Fax Number:
304-645-4492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1478 MAPLEWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RONCEVERTE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24970-8017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-645-4406
Provider Business Practice Location Address Fax Number:
304-645-4492
Provider Enumeration Date:
09/30/2005

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: 207Q00000X , with the licence number:  1139 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0041844000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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