1720488018 NPI number — MR. SAMUEL JACOB KOROLEV MS, ATC/L

Table of content: MR. SAMUEL JACOB KOROLEV MS, ATC/L (NPI 1720488018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720488018 NPI number — MR. SAMUEL JACOB KOROLEV MS, ATC/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOROLEV
Provider First Name:
SAMUEL
Provider Middle Name:
JACOB
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOROLEV
Provider Other First Name:
SAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720488018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
631 S COLLEGE AVENUE
Provider Second Line Business Mailing Address:
DFH ATHLETIC TRAINING ROOM
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19716-2010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-831-8857
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
631 S COLLEGE AVENUE
Provider Second Line Business Practice Location Address:
DFH ATHLETIC TRAINING ROOM
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19716-2010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-831-8857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2014

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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