Provider Demographics
NPI:1255582078
Name:MARTIN E. SAMUEL, DDS,MD,SC
Entity type:Organization
Organization Name:MARTIN E. SAMUEL, DDS,MD,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:GRUNERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-281-9824
Mailing Address - Street 1:2741 W LAYTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2600
Mailing Address - Country:US
Mailing Address - Phone:414-281-9824
Mailing Address - Fax:414-281-9835
Practice Address - Street 1:2741 W LAYTON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2600
Practice Address - Country:US
Practice Address - Phone:414-281-9824
Practice Address - Fax:414-281-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30307900Medicaid
WI30307900Medicaid