Provider Demographics
NPI:1780622761
Name:MARDINI, SAMUEL HOUSSAM (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:HOUSSAM
Last Name:MARDINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HOUSSAM
Other - Middle Name:EDDIN
Other - Last Name:MARDINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:UK DIVISION OF DIGESTIVE DISEASES
Mailing Address - Street 2:800 ROSE ST, MN654
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0298
Mailing Address - Country:US
Mailing Address - Phone:859-323-0079
Mailing Address - Fax:859-257-9287
Practice Address - Street 1:UK DIVISION OF DIGESTIVE DISEASES
Practice Address - Street 2:800 ROSE ST, MN654
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0298
Practice Address - Country:US
Practice Address - Phone:859-323-0079
Practice Address - Fax:859-257-9287
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24021207RG0100X, 207R00000X
KY37438207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH66206Medicare UPIN