Provider Demographics
NPI:1003002262
Name:BRADLEY E. SAMUELSON, MD PA
Entity Type:Organization
Organization Name:BRADLEY E. SAMUELSON, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-687-7100
Mailing Address - Street 1:1004 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5007
Mailing Address - Country:US
Mailing Address - Phone:940-687-7100
Mailing Address - Fax:940-687-7104
Practice Address - Street 1:1004 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5007
Practice Address - Country:US
Practice Address - Phone:940-687-7100
Practice Address - Fax:940-687-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00555YMedicare PIN