Provider Demographics
NPI:1891767539
Name:RALSTON, SAMUEL WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:WARREN
Last Name:RALSTON
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 18962
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4084
Mailing Address - Country:US
Mailing Address - Phone:800-566-5050
Mailing Address - Fax:
Practice Address - Street 1:6101 WOODWAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6111
Practice Address - Country:US
Practice Address - Phone:254-537-6300
Practice Address - Fax:254-537-6301
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116984902Medicaid
TX084249401Medicaid
TX116984904Medicaid
TX80Y494OtherBC BS
TX00N59XOtherBCBS OF TX
TX80Y494Medicare ID - Type Unspecified
TX80Y494OtherBC BS
TX116984904Medicaid
B25763Medicare UPIN
080037943Medicare PIN
00N59XMedicare PIN