Provider Demographics
NPI:1013924695
Name:AMPORFUL, SAM G (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:G
Last Name:AMPORFUL
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 1:721 RIVERSIDE DRIVE LANE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2658
Mailing Address - Country:US
Mailing Address - Phone:478-259-3439
Mailing Address - Fax:478-254-2733
Practice Address - Street 1:721 RIVERSIDE DRIVE LANE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2658
Practice Address - Country:US
Practice Address - Phone:478-259-3439
Practice Address - Fax:478-254-2733
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030940207Q00000X, 208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000380619OMedicaid
GA202I083236OtherACTIVE MEDICARE ID FOR URGENTONE
GA0000380619IMedicaid
GA000380619PMedicaid
SCGA1103Medicaid
GAD28796Medicare UPIN
GA000380619OMedicaid