Provider Demographics
NPI:1508887175
Name:SAMUELS, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:SAMUELS
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 1:1604 GUNBARREL RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3125
Mailing Address - Country:US
Mailing Address - Phone:423-648-2395
Mailing Address - Fax:423-648-7542
Practice Address - Street 1:1604 GUNBARREL RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3125
Practice Address - Country:US
Practice Address - Phone:423-893-7226
Practice Address - Fax:423-893-7398
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0394602085R0202X
TNMD262252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00635852Medicaid
TN3805936Medicaid
GA004250OtherBCBS OF GA
TN3018076OtherBCBS OF TN
TN4073023OtherBCBS OF TN
GA498282OtherBCBS OF GA
GA30BDLGCMedicare PIN
GAP00103216Medicare PIN
GA00635852Medicaid
GA300059073Medicare PIN
TN4073023OtherBCBS OF TN
TN3018076OtherBCBS OF TN
TN3805936Medicare PIN
TNP00048431Medicare PIN