Provider Demographics
NPI:1235398439
Name:SAMUEL S. IM, MD, INC.
Entity Type:Organization
Organization Name:SAMUEL S. IM, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:IM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-900-1012
Mailing Address - Street 1:PO BOX 4316
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-4316
Mailing Address - Country:US
Mailing Address - Phone:562-900-1012
Mailing Address - Fax:562-789-4440
Practice Address - Street 1:12462 PUTNAM ST
Practice Address - Street 2:SUITE 303
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1048
Practice Address - Country:US
Practice Address - Phone:562-900-1012
Practice Address - Fax:562-789-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71341207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH49953Medicare UPIN
CAW22447Medicare PIN