Provider Demographics
NPI:1427037910
Name:SAMUEL, ROTIMI B (MD)
Entity Type:Individual
Prefix:
First Name:ROTIMI
Middle Name:B
Last Name:SAMUEL
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 1:810 13TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1333
Mailing Address - Country:US
Mailing Address - Phone:229-878-0404
Mailing Address - Fax:229-878-0690
Practice Address - Street 1:810 13TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1333
Practice Address - Country:US
Practice Address - Phone:229-878-0404
Practice Address - Fax:229-878-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130523208M00000X
GA044082207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G71396Medicare UPIN