Provider Demographics
NPI:1508954181
Name:LEVINE, SAMUEL C (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:C
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:CAREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIAN
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-5900
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:PWB 8TH FLOOR, CLINIC 8A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-626-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30278207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0051221Medicaid
MN274082600Medicaid
MN10-00019OtherMEDICA PRIMARY
MN10-22589OtherMEDICA CHOICE
MN2T080LEOtherBLUE CROSS BLUE SHIELD
WI30778200Medicaid
MNHP22089OtherHEALTH PARTNERS
MN100884OtherUCARE
MN065524OtherFAIRVIEW
MN607398OtherARAZ
MN1009211OtherPREFERRED ONE
MN10-22589OtherMEDICA CHOICE
MN040004939Medicare ID - Type UnspecifiedRAILROAD
MT0051221Medicaid