Provider Demographics
NPI:1396911087
Name:KOO, SAM B (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:B
Last Name:KOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-7662
Mailing Address - Fax:513-354-7601
Practice Address - Street 1:6480 HARRISON AVE STE 100
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7961
Practice Address - Country:US
Practice Address - Phone:513-354-3700
Practice Address - Fax:513-354-7601
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35120976207X00000X, 207XS0106X, 207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200991620Medicaid
IN000000671442OtherANTHEM PROVIDER NUMBER
IN200991620Medicaid