Provider Demographics
NPI:1639239049
Name:RYU, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RYU
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 1:101 NICOLLS RD
Mailing Address - Street 2:LEVLE 2 RADIATION ONCOLOGY
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-7770
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:LEVLE 2 RADIATION ONCOLOGY
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-7028
Practice Address - Country:US
Practice Address - Phone:631-444-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010619492085R0001X
NY2066482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SR061949OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262320OtherBLUE CROSS-BLUE CROSS
SR061949OtherCHAMPUS-CHAMPUS
MI415031010Medicaid
MI415031010Medicaid
G50299Medicare UPIN