Provider Demographics
NPI:1255305017
Name:SAMUELS, FANIA (MD)
Entity Type:Individual
Prefix:
First Name:FANIA
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-671-3920
Mailing Address - Fax:215-671-3939
Practice Address - Street 1:10160 BUSTLETON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3749
Practice Address - Country:US
Practice Address - Phone:215-671-3920
Practice Address - Fax:215-671-3939
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042597E207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0833050000OtherKEYSTONE IBC
PA30133381OtherKEYSTONE FIRST
PA8692853OtherAETNA
PA0015494060015Medicaid
PA806944OtherHIGHMARK BLUE SHIELD
PA001549406Medicaid
PA8692853OtherAETNA
PA806944GH2Medicare PIN