Provider Demographics
NPI:1891960787
Name:SAMUEL W. VALLERY, M.D., P.A.
Entity Type:Organization
Organization Name:SAMUEL W. VALLERY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:VALLERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-609-2300
Mailing Address - Street 1:1 MERCY LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6442
Mailing Address - Country:US
Mailing Address - Phone:501-609-2300
Mailing Address - Fax:501-609-2301
Practice Address - Street 1:1 MERCY LN
Practice Address - Street 2:SUITE 205
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6442
Practice Address - Country:US
Practice Address - Phone:501-609-2300
Practice Address - Fax:501-609-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0503207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166792002Medicaid