Provider Demographics
NPI:1750801288
Name:SAMIRATEDU, MICHAEL M (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:SAMIRATEDU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3815 FABER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8533
Mailing Address - Country:US
Mailing Address - Phone:843-767-9312
Mailing Address - Fax:843-767-9313
Practice Address - Street 1:3815 FABER PLACE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8533
Practice Address - Country:US
Practice Address - Phone:843-767-9312
Practice Address - Fax:843-767-9313
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDO83825207RN0300X
SC83825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC838260Medicaid