Provider Demographics
NPI:1457046591
Name:ALLISON, SAMUEL WALTER
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WALTER
Last Name:ALLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RUNNING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-5344
Mailing Address - Country:US
Mailing Address - Phone:973-600-1179
Mailing Address - Fax:
Practice Address - Street 1:7711 QUARTERFIELD RD STE C2
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4591
Practice Address - Country:US
Practice Address - Phone:410-487-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist