Provider Demographics
NPI:1528043130
Name:PEGRAM, SAMUEL B (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:B
Last Name:PEGRAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2000 S MAYS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7580
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:512-244-2895
Practice Address - Street 1:3316 WILLIAMS DR STE 150
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2891
Practice Address - Country:US
Practice Address - Phone:512-244-4272
Practice Address - Fax:512-244-2895
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2021-08-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF9937207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128203006Medicaid
TX128203006Medicaid
TX109324702Medicaid
TXB25434Medicare UPIN