Provider Demographics
NPI:1669477055
Name:COLLINS, SAMUEL BROWN (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BROWN
Last Name:COLLINS
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-332-1072
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-1400
Practice Address - Fax:910-332-1072
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400758207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01-28698OtherUNITED HEALTHCARE
NC930077053OtherRAILROAD MEDICARE
NC930084654OtherRAILROAD MEDICARE
NCB4543OtherMEDCOST
NC12191OtherBCBS
NC8912191Medicaid
SCQ0075FMedicaid
NC2208891AMedicare PIN
NCB4543OtherMEDCOST
NC2208891CMedicare PIN