Provider Demographics
NPI:1528390952
Name:S SAMUEL IM MD PC
Entity Type:Organization
Organization Name:S SAMUEL IM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUNGGEUN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:IM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-969-6211
Mailing Address - Street 1:485 E COLUMBIA AVE
Mailing Address - Street 2:SUITE 11 A
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-5499
Mailing Address - Country:US
Mailing Address - Phone:269-969-6211
Mailing Address - Fax:269-969-6049
Practice Address - Street 1:485 E COLUMBIA AVE
Practice Address - Street 2:SUITE 11 A
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-5499
Practice Address - Country:US
Practice Address - Phone:269-969-6211
Practice Address - Fax:269-969-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1077038Medicaid
MI1077038Medicaid