Provider Demographics
NPI:1033132709
Name:SAMUELS, PAULINE M (MD)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:M
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W COHAWKIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1145
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:856-423-0823
Practice Address - Street 1:3712 GARRETT RD FL 1
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-3544
Practice Address - Country:US
Practice Address - Phone:610-394-6666
Practice Address - Fax:610-394-6667
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056958L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016036540004Medicaid
PA0561OtherAETNA
PA2147326001OtherKEYSTONE
PAG001019000OtherAMERICHOICE
PA0016036540005Medicaid
PAG001019000OtherAMERICHOICE
PAG17825Medicare UPIN