Provider Demographics
NPI:1821074345
Name:KAGAN, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:KAGAN
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 1:925 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-3116
Mailing Address - Country:US
Mailing Address - Phone:401-884-5333
Mailing Address - Fax:401-884-5664
Practice Address - Street 1:925 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-3116
Practice Address - Country:US
Practice Address - Phone:401-884-5333
Practice Address - Fax:401-884-5664
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI8504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISK01749Medicaid
RISK01749Medicaid
RI089020173Medicare ID - Type Unspecified