Provider Demographics
NPI:1649641200
Name:SAM W. HUDDLESTON IV MD PC
Entity type:Organization
Organization Name:SAM W. HUDDLESTON IV MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-245-7080
Mailing Address - Street 1:2002 BROOKSIDE DR
Mailing Address - Street 2:SUITE# 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4634
Mailing Address - Country:US
Mailing Address - Phone:423-245-7080
Mailing Address - Fax:423-245-7875
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE# 201
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-245-7080
Practice Address - Fax:423-245-7875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3032417Medicare PIN