Provider Demographics
NPI:1003898412
Name:ALLEN, SAMUEL M II (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:M
Last Name:ALLEN
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5208
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5208
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:603 S ARCHUSA AVE
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2331
Practice Address - Country:US
Practice Address - Phone:601-776-2123
Practice Address - Fax:601-776-6006
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010065827OtherRAILROAD MEDICARE
730-07862OtherBLUE CROSS OF AL
MS00014132Medicaid
080003576Medicare ID - Type Unspecified
MS00014132Medicaid