Provider Demographics
NPI:1447240510
Name:FEATHERSTON, SAMUEL L (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:FEATHERSTON
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 1:1707 MEADOWS LN STE G
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-7201
Mailing Address - Country:US
Mailing Address - Phone:912-535-5120
Mailing Address - Fax:912-535-2015
Practice Address - Street 1:1707 MEADOWS LN STE G
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7201
Practice Address - Country:US
Practice Address - Phone:912-535-5120
Practice Address - Fax:912-535-2015
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119873207R00000X
GA055045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16743WMedicare PIN
FL012985400Medicaid
GA11SCGGKMedicare PIN
GA10064424OtherAMERIGROUP
GAP00372918OtherRR MEDICARE
FL16743XMedicare PIN
FL273200900Medicaid