Provider Demographics
NPI:1457444549
Name:LANEY, SAMUEL M (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:LANEY
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 1:801 SEVENTH AVE
Mailing Address - Street 2:REVENUE MANAGEMENT
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:682-885-4157
Mailing Address - Fax:682-885-1903
Practice Address - Street 1:901 SEVENTH AVE
Practice Address - Street 2:STE 120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:682-885-2500
Practice Address - Fax:682-885-2510
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG82322084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U87ZOtherBCBSTX GRP PIN
TX0772105OtherCIGNA PIN
TX1640392OtherFIRSTHEALTH PIN
TX124225OtherSUPERIOR PIN
TX1392896OtherUHC PIN
TX413473OtherPHCS PIN
TX87V782OtherBCBSTX IND PIN
1750369203OtherGRP NPI NUMBER
TX10028600OtherAMERIGROUP PIN
TX4292606OtherAETNA PIN
TX1640392OtherFIRSTHEALTH PIN
TX124225OtherSUPERIOR PIN
TX00L98SMedicare ID - Type UnspecifiedGRP MEDICARE