Provider Demographics
NPI:1558304642
Name:SAMUEL, TERRI T (MD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:T
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:ROOM 1204A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-6793
Practice Address - Fax:317-962-8281
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010617302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00366169OtherRAILROAD MEDICARE
INP00742679OtherRAILROAD MEDICARE
IN000000489622OtherANTHEM BCBS
IN200832500Medicaid
INP00366169OtherRAILROAD MEDICARE
INP00742679OtherRAILROAD MEDICARE