Provider Demographics
NPI:1942296074
Name:BURNETT III, SAMUEL T (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:BURNETT III
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 1:104 LINER DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2310
Mailing Address - Country:US
Mailing Address - Phone:864-227-1115
Mailing Address - Fax:864-227-2046
Practice Address - Street 1:104 LINER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2310
Practice Address - Country:US
Practice Address - Phone:864-227-1115
Practice Address - Fax:864-227-2046
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC17063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL10780Medicaid
SCL10780Medicaid