Provider Demographics
NPI:1467459040
Name:DURHAM, SAMUEL JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JEROME
Last Name:DURHAM
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 1:2220 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2370
Mailing Address - Country:US
Mailing Address - Phone:785-623-6544
Mailing Address - Fax:785-623-2192
Practice Address - Street 1:2220 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2370
Practice Address - Country:US
Practice Address - Phone:785-623-6544
Practice Address - Fax:785-623-2192
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010746482086S0129X
OH659382086S0129X
KS0440775208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0941191Medicaid
OHDU0751176Medicare ID - Type Unspecified
B34342Medicare UPIN