Provider Demographics
NPI:1790788081
Name:BYRD, SAMUEL J (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:BYRD
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:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-0665
Mailing Address - Country:US
Mailing Address - Phone:812-882-2400
Mailing Address - Fax:812-882-2422
Practice Address - Street 1:1621 WILLOW ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4211
Practice Address - Country:US
Practice Address - Phone:812-882-2400
Practice Address - Fax:812-882-2422
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058714A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000325459OtherBCBS PIN
IN200475520Medicaid
IN200475520Medicaid
IN849950HMedicare ID - Type Unspecified
IN257900BMedicare PIN