Provider Demographics
NPI:1063473908
Name:SAMUEL, RUSSELL H (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:H
Last Name:SAMUEL
Suffix:
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 1:104 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-759-5406
Mailing Address - Fax:516-759-5537
Practice Address - Street 1:104 FOREST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542
Practice Address - Country:US
Practice Address - Phone:516-759-5406
Practice Address - Fax:516-759-5537
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161000208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E20497Medicare UPIN
NY30F802T6T1Medicare PIN