Provider Demographics
NPI:1154664282
Name:SOUTH, SAMUEL D (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:D
Last Name:SOUTH
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 1:30 N 1900 E RM 3C344
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-213-2598
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST STE 500
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:719-364-6488
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5267810-1205208600000X, 2086S0102X
CODR.0068718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care