Provider Demographics
NPI:1396776027
Name:SAMUELS, BRIAN LOUIS (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LOUIS
Last Name:SAMUELS
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 1:980 W IRONWOOD DR STE 207
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-755-2804
Mailing Address - Fax:208-765-0277
Practice Address - Street 1:980 W IRONWOOD DR STE 207
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-755-2804
Practice Address - Fax:208-765-0277
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60316942207RH0003X
IDM-8989207RX0202X
IDM8989207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806822500Medicaid
WAG8917394Medicare UPIN
ID806822500Medicaid
ID1122391Medicare PIN
ID20003036Medicare UPIN