Provider Demographics
NPI:1043408230
Name:SAMUEL CHAN, M.D.
Entity Type:Organization
Organization Name:SAMUEL CHAN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-797-8822
Mailing Address - Street 1:324 E ANTIETAM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5754
Mailing Address - Country:US
Mailing Address - Phone:301-797-8822
Mailing Address - Fax:301-790-3748
Practice Address - Street 1:324 E ANTIETAM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5754
Practice Address - Country:US
Practice Address - Phone:301-797-8822
Practice Address - Fax:301-790-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36655172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W111OtherBLUE SHIELD OF D.C.
MDCJ4601OtherRAILROAD MEDICARE
MDKDZ2SAOtherCAREFIRST BLUECROSS BLUES
MDKDZ2SAOtherCAREFIRST BLUECROSS BLUES