Provider Demographics
NPI:1710949839
Name:SAM, CATHERINE THYRA (MD)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:THYRA
Last Name:SAM
Suffix:
Gender:F
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3920 ST FRANCIS WAY STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4917
Practice Address - Country:US
Practice Address - Phone:765-428-5990
Practice Address - Fax:765-428-5896
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065303A207V00000X
PAMD419761207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200913730Medicaid
PA1011054020003Medicaid
IN234340NMedicare PIN
PA1011054020003Medicaid
PA082278PZPMedicare ID - Type Unspecified