Provider Demographics
NPI:1417957465
Name:BUB, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:BUB
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 1:619 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-3031
Mailing Address - Country:US
Mailing Address - Phone:610-628-8200
Mailing Address - Fax:610-965-6595
Practice Address - Street 1:619 DALTON ST
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-3031
Practice Address - Country:US
Practice Address - Phone:610-628-8200
Practice Address - Fax:610-965-6595
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020773E207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014636420001Medicaid
PAB33578Medicare UPIN
26455Medicare ID - Type Unspecified