Provider Demographics
NPI:1700988623
Name:HAZELL, SAMUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:HAZELL
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:1859 SAVAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4726
Practice Address - Country:US
Practice Address - Phone:843-723-2835
Practice Address - Fax:843-722-8948
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10048208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5551OtherMEDICARE GROUP #
SCP00638310OtherRAILROAD MEDICARE
P00879497OtherRR MEDICARE RSFP
SCGP4953OtherMEDICAID GROUP
SC100483Medicaid
SCB91424Medicare UPIN
SCB914249223Medicare PIN
P00879497OtherRR MEDICARE RSFP