Provider Demographics
NPI:1043442080
Name:SAM PENG MD PC
Entity Type:Organization
Organization Name:SAM PENG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:Q
Authorized Official - Last Name:PENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-820-3855
Mailing Address - Street 1:1622 RIVERGREEN BND SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-8546
Mailing Address - Country:US
Mailing Address - Phone:770-587-5485
Mailing Address - Fax:
Practice Address - Street 1:1622 RIVERGREEN BND SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-8546
Practice Address - Country:US
Practice Address - Phone:770-587-5485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057232207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty