Provider Demographics
NPI:1760014344
Name:SAM CLINIC
Entity Type:Organization
Organization Name:SAM CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONY
Authorized Official - Middle Name:N
Authorized Official - Last Name:VANBANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-666-5116
Mailing Address - Street 1:1701 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-4898
Mailing Address - Country:US
Mailing Address - Phone:720-666-5116
Mailing Address - Fax:303-934-4036
Practice Address - Street 1:1701 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4898
Practice Address - Country:US
Practice Address - Phone:720-666-5116
Practice Address - Fax:303-934-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1679747216OtherPERSONAL NPI NUMBER