Provider Demographics
NPI:1619991544
Name:ONG, SAMUEL WISCO (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WISCO
Last Name:ONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CLEVELAND ST
Mailing Address - Street 2:STE. 250
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-9716
Mailing Address - Country:US
Mailing Address - Phone:931-484-8100
Mailing Address - Fax:931-707-9135
Practice Address - Street 1:49 CLEVELAND ST
Practice Address - Street 2:STE. 250
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-9716
Practice Address - Country:US
Practice Address - Phone:931-484-8100
Practice Address - Fax:931-707-9135
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37580207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00060241OtherRAILROAD MEDICARE
G96113Medicare UPIN