Provider Demographics
NPI:1598735466
Name:SHANE T SAMPSON MD INC
Entity Type:Organization
Organization Name:SHANE T SAMPSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-459-5057
Mailing Address - Street 1:122 MARTZ ST
Mailing Address - Street 2:PO BOX 960
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1052
Mailing Address - Country:US
Mailing Address - Phone:937-459-5057
Mailing Address - Fax:937-459-5285
Practice Address - Street 1:122 MARTZ ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1052
Practice Address - Country:US
Practice Address - Phone:937-459-5057
Practice Address - Fax:937-459-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063468207Q00000X
IN01038529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0891343Medicaid
OH0718151Medicare ID - Type Unspecified
E20579Medicare UPIN