Provider Demographics
NPI:1609972082
Name:MERVYN J. SAMUEL, M.D., INC.
Entity Type:Organization
Organization Name:MERVYN J. SAMUEL, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERVYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-882-4343
Mailing Address - Street 1:200 BRADENTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017
Mailing Address - Country:US
Mailing Address - Phone:614-793-1982
Mailing Address - Fax:
Practice Address - Street 1:5910 CLEVELAND AVE.
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231
Practice Address - Country:US
Practice Address - Phone:614-882-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-5794-S207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238317Medicaid
OHSA0425751Medicare ID - Type Unspecified
A75689Medicare UPIN