Provider Demographics
NPI:1073700837
Name:DEBRA C SAMS DO
Entity Type:Organization
Organization Name:DEBRA C SAMS DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRITES-SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-645-4406
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970
Practice Address - Country:US
Practice Address - Phone:304-645-4406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVE35409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010441Medicaid
E35409Medicare UPIN