Provider Demographics
NPI:1922071166
Name:CHAN, SAM (DC)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9007
Mailing Address - Country:US
Mailing Address - Phone:989-729-2273
Mailing Address - Fax:989-723-4836
Practice Address - Street 1:1010 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9007
Practice Address - Country:US
Practice Address - Phone:989-729-2273
Practice Address - Fax:989-723-4836
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G810160OtherBCBSM- GROUP
MI1015769OtherMCLAREN HEALTH PLAN
MI692220OtherACN GROUP
MI44-00276OtherPHYSICIANS HEALTH PLAN
MI4843805Medicaid
MI44-70072OtherPHYSICIANS HEALTH PLAN
MI7605647OtherAETNA US HEALTHCARE PPO
MI950G810560OtherBCBSM PROVIDER ID
MI383374689OtherPPOM
MI200000001732OtherPHPMM-FC
MI9412258OtherPRIVATE HEALTHCARE SYSTEM
MI1015769OtherMCLAREN HEALTH PLAN
MI950G810160OtherBCBSM- GROUP
MIN32500013Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE