Provider Demographics
NPI:1689644981
Name:WEST, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WEST
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 1:500 W BUFFALO ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117-1208
Mailing Address - Country:US
Mailing Address - Phone:269-469-0589
Mailing Address - Fax:269-469-1980
Practice Address - Street 1:500 W BUFFALO ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1208
Practice Address - Country:US
Practice Address - Phone:269-469-0589
Practice Address - Fax:269-469-1980
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100181790Medicaid
IN217230IMedicare PIN
MIP48230001Medicare PIN