Provider Demographics
NPI:1912394800
Name:GRODMAN, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GRODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 KANAWHA BLVD E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-2470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23284
Practice Address - Country:US
Practice Address - Phone:804-828-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-19
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309389207P00000X
CAA155406207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine