Provider Demographics
NPI:1003377003
Name:METCALF, SAMUEL GRIFFIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GRIFFIN
Last Name:METCALF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GRIFFIN
Other - Middle Name:
Other - Last Name:METCALF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:118 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3107
Mailing Address - Country:US
Mailing Address - Phone:662-534-0898
Mailing Address - Fax:662-534-8905
Practice Address - Street 1:118 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3107
Practice Address - Country:US
Practice Address - Phone:662-534-0898
Practice Address - Fax:662-534-8905
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29519208000000X, 207R00000X
MS390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200005489Medicaid