Provider Demographics
NPI:1720159346
Name:MEDARIS, SAMUEL MEARL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MEARL
Last Name:MEDARIS
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 1:1010 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-729-0077
Mailing Address - Fax:314-729-0101
Practice Address - Street 1:501 W PINE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1439
Practice Address - Country:US
Practice Address - Phone:573-756-8888
Practice Address - Fax:573-701-9547
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40298207Y00000X
NE23454207Y00000X
MO2020000124207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026440200Medicaid
NE10026442200Medicaid
NENA2595002Medicare PIN
NE10026440200Medicaid